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of trauma.^7 Much detail about the hip pain should be elicited, including the location and severity of the pain, time of onset, specific quality, alleviating, aggravating, or associated factors, whether the pain is focal or diffuse. Additionally, similar pains, popping or locking symptoms, night pain, and any accompany- ing numbness or weakness are important to document. Back pain and hip pain will often coexist, so care should be taken to note the severity of one pain relative to the other. Radicular pain may exist with either hip or lumbar spine pathology and is unre- liable as a differentiating factor. However, weakness, numbness, and paresthesias in the lower extremity are suggestive of neural compression, often occurring in the lumbar spine. An inquiry should also be made into any treatment the patient has had and its effectiveness. This treatment may include pharmaceuticals such as nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, or the use of any assistive devices. To further aid in the diagnosis, the patient’s activity level should be delineated. Specifically, the ability to complete activi- ties of daily living, work responsibilities, and higher-impact activities should be documented. Participation in certain sports (running, soccer, ballet, hockey, golf, tennis, martial arts, and rugby) can be important since these sports are often associated with specific hip disorders. 8, A thorough past medical and family history is critical. Past medical considerations should include hip disorders or disloca- tion during birth or infancy, past surgeries or major illnesses, and any history of trauma. Family history should include hip dis- locations or any hip disorder, degenerative joint disease, rheu- matologic disorders, and cancer. Also, the physician should be keenly aware of “red flags” such as fever, malaise, night sweats, weight loss, night pain, intravenous drug use, cancer history, or known immunocompromised state.^10 These red flags may indicate systemic problems, and further diagnostic tests may be necessary. Hip conditions can also be related to general medi- cal conditions within the gastrointestinal, genitourinary, neuro- logical, or vascular systems, making a complete, general physical examination an important component of the hip examination.
PHYSICAL EXAMINATION
Any orthopaedic physical examination should begin with an eval- uation of the patient’s general appearance, which may provide clues to the source of pain. The patient may then be brought to the standing position for the first portion of the exam.
C H A P T E R
Physical Examination of the Hip
INTRODUCTION
As our understanding and treatment of hip pathology improves, a systematic, consistent, and reproducible means of clinically evaluating the hip is imperative. While a limp, groin pain, and limited internal rotation are often indicators of hip pathology,^1 the hip is overlooked as the original source of pain or pathology in 60% of primary hip disorders.^2 Hip pain can be ambiguous in its nature and origin, and pathologies of the hip and low back interact with one another and are easily confused. Hip problems can stem from disorders of the paravertebral muscles, which cause soft tissue instability and irregular tension on the hip.^3 Hip pain can also cause back pain by way of muscle con- tractures of the iliopsoas and the hamstrings or through sec- ondary leg length discrepancy.^1 A systematic and reproducible physical examination of the hip is therefore a necessity for cor- rect diagnosis as well as longitudinal follow-up. The hip is a focal point of initiation for running and walking and can bear forces equal to over five times body weight during running or jumping.^4 Because the hip is almost universally sub- jected to high loads and extremes of motion during sport, hip pain is a common complaint in athletes. In one study, pathol- ogy of the hip accounted for 2.5% of adult athletic injuries and 5% to 9% of high school athletic injuries.^5 Hip pain is especially frequent in sports such as soccer, ballet, hockey, martial arts, rugby, and running.^5 A recent study of injuries in the National Basketball Association over 17 years found a total of 1,340 hip- related injuries causing 4,753 games missed. 6 This chapter will focus on techniques to assess hip pathology in several dimensions: location (intra-articular vs. extra-articular), compartment (posterior, anterior, or lateral), and tissue involved (bony, ligamentous, or musculotendinous). The physical exami- nation will also aid in differentiating between pain originating from the hip and back. This chapter comprises six sections. The first section will describe the patient history, and the subsequent five sections will correspond to the five positions in which the physical examination will be conducted: standing, sitting, supine, lateral, and prone.
PATIENT HISTORY
As with all clinical encounters, a detailed history is essential to the final diagnosis and should begin in a traditional manner with the patient’s age, chief complaint, and the presence or absence
Benjamin G. Domb
Adam Brooks
Carlos Guanche
Chapter 4 • Physical Examination of the Hip 63
greater than 2 cm while the patient lifts the contralateral leg off the floor. By lifting the right leg, one is testing the left abductor muscles and neural loop, and vice versa. A positive sign therefore suggests incompetence of abductor function. The maneuver should be performed first on the unaffected side to establish a comparative norm. Finally, laxity can be assessed by checking for hyperextension of the knee and elbow, along with the thumb-to-wrist exam. The thumb-to-wrist exam involves an attempt to touch the anterior forearm with the thumb (Fig. 4.2). A positive thumb-to-wrist exam along with hyperextension of the knee and elbow beyond 5 ° is suggestive of generalized hyperlaxity of the ligaments.^9
SITTING
The sitting examination consists of three parts: circulatory, neurological, and rotational. As with all aspects of the physi- cal examination, bilateral evaluation in the seated position is essential. The circulatory examination requires checking the dorsalis, pedis, and posterior tibial pulses and inspecting the skin and lymphatics around the hip. This pulse is absent in 2% to 3% of normal, healthy young adults, so its absence alone would not be sufficient to conclude a vascular pathology. 15 Both sides should be compared for any scarring of the skin or lymphadenopathy.
STANDING
The standing examination consists of four parts: gait, alignment, Trendelenburg test, and the laxity test. Because the hip is essen- tial to walk, hip pathologies will often visibly affect a patient’s gait.^7 Six to eight full strides should be observed from both the frontal and sagittal planes, paying close attention to stride length, internal or external rotation of the foot, pelvic rotation, and the stance phase.^11 Any snapping or clicking should be noted since these noises may imply psoas contractures, iliotibial (IT) band tightness, or intra-articular pathology. The patient should be asked to rotate his or her hip to recreate the noise in order to differentiate between internal and external snapping.^8 One of several types of abnormal gaits related to hip pain including antalgic gait, pelvic wink, Trendelenburg gait, excessive pelvic internal or external rotation, and true or false leg length discrepancies may be noted. An antalgic gait is one during which the patient limps to minimize the stance phase on the painful side thus limiting weight bearing. This gait pattern may indicate pain in the hip, pelvis, or lower back.12,13^ A pelvic wink is rota- tion in excess of 40° in the axial plane toward the affected hip when terminally extending the hip. This dysfunction can signify hip flexion contractures when lumbar lordosis or a forward- stooping posture is present or can indicate an internal hip pathol- ogy. Trendelenburg gait, or abductor lurch, is characterized by a lurching of the trunk toward the affected side during stance phase. The abductor muscles are responsible for stabilizing the pelvis during stance phase. If those muscles are compromised, the patient will compensate by lurching to the ipsilateral side to prevent the pelvis from sagging. In the case of intra-articular hip pathology, patients will frequently walk with a Trendelenburg gait in order to avoid increased joint reactive forces that occur with abductor contraction. Excessive internal or external rotation of the hip should be noted during the gait examination and will be discussed during the seated examination. Finally, a short leg limp during gait may imply either IT band pathology or true or false leg length discrepancy (discussed later). The alignment portion of the examination focuses on leg length discrepancy and spinal alignment. Several methods exist to assess possible true or false leg length discrepancy, which is especially important if a short leg limp is noted during the gait exam. First, examine the height of the shoulders relative to the ipsilateral iliac crest. Second, assess pelvic tilt, a condition that may indicate leg length discrepancy. Third, measure the dis- tance from the anterior superior iliac spine (ASIS) to the ipsi- lateral medial malleolus. Differences in these measurements suggest a true leg length discrepancy in which the proportions of the bones are different on each side of the body.^14 If there is a short leg limp but no true leg length discrepancy is noted, conditions such as scoliosis, muscle spasms, or pelvic deformi- ties may contribute.^8 The assessment of spinal alignment involves inspection from two positions. First, the patient stands in front of the examiner and bends forward while the back is inspected for trunk rota- tion consistent with scoliosis, a contributing factor in functional leg length discrepancy. Second, the patient is viewed laterally for excessive lumbar lordosis or paravertebral muscle spasms. Hip flexor contractures can cause increased lumbar lordosis, and paravertebral muscle spasms can cause hip pain by placing abnormal tension on the hip.^3 The next part of the standing examination is the Trendelenburg test (Fig. 4.1). A positive test consists of sagging of the pelvis
[AU1]
[AU2]
Figure 4.1. Trendelenburg sign is a test of the contralateral leg ab-
ductors. The patient lifts the leg and the pelvis is assessed for at least 2 cm of sag. (From Berry D, Steinman Orthopaedic Surgery Essentials: Adult Reconstruction. Philadelphia, 2007 with permission.) (^) [AU3]
Chapter 4 • Physical Examination of the Hip 65
The final part of the seated examination involves evaluation of internal and external rotation of the hip. Rotation is best evaluated in the seated position because the hip is stabilized at a 90 ° angle, avoiding variability due to changes in flexion angle.^10 In addition, the seated position stabilizes the pelvis, which is dif- fi cult to accomplish in the supine position. The range of inter- nal rotation of the hip is within 20° to 35°, and external rotation is within 30° to 70°. Additionally, the terminally extended hip should internally rotate at least 10°. Loss of internal rotation is one of the initial signals for such problems as arthritis, effusion, and other internal derangements, as well as for slipped capital femoral epiphysis and muscular contractures. 22 Excessive inter- nal rotation coupled with diminished external rotation sug- gests increased femoral anteversion.^14 Signifi cant differences in rotational measurements from one side to another, whether or not in normal range, can indicate FAI or abnormal femoral or acetabular version.^1
SUPINE
The supine examination includes the continued assessment of a range of motion, an abdominal exam, and a trauma assessment followed by provocative testing. To examine flexion, have the patient flex his or her knees and hips toward his or her chest and observe both sides at once. The limit of normal flexion is around 120°; significant loss of flexion can limit the patient’s ability to perform activities of daily living. 7 When evaluating abduction and an adduction range of motion, one should ref- erence the position of the shaft of the femur to the midline of the pelvis. To test abduction, hold the ankle while support- ing the leg and manually abduct the leg. Normal abduction is approximately 45°. Adductor contractures can cause a dimin-
ished abduction range of motion. Bringing the leg across the other leg tests adduction. Normal range is 20° to 30°, but may be diminished in the setting of abductor contracture. Next in the supine examination is the assessment of the abdominal/ilioinguinal area, which begins with the palpation of several landmarks. Palpate the femoral pulse at the femo- ral triangle. Search for any fascial hernias or other masses in the abdominal region by having the patient contract the rectus abdominus and oblique muscles. Palpate any masses or her- nias, if present. Palpate the adductor tubercle (Fig. 4.5A) as the patient adducts the leg; reproduction of pain may indicate adductor tendonitis. Palpate the pubic symphysis (Fig. 4.5A); if there is tenderness, one or more of several issues may be pres- ent including fracture, trauma, calcification, or osteitis pubis, and further investigation is required. Pelvic stability is assessed by pushing down on the bilateral iliac crests, looking for inde- pendent motion of the hemipelvises. Finally, attempt to elicit the Tinel sign at the femoral nerve by percussing the femoral nerve at the level of the ilioinguinal ligament. A positive Tinel sign occurs with tingling along the femoral nerve, possibly indi- cating a neurological pathology. A generalized hip trauma examination includes log roll, heel strike, and the Stinchfield tests. All should cause marked pain in the presence of a hip fracture but may also be painful with intra- articular derangement. Rotating the leg internally and exter- nally in the supine position performs the log roll. Striking the fi st against the heel, creating an axial load on the hip, performs the heel strike. With the Stinchfield test, the patient must raise the fully extended leg against the pressure of the examiner’s hand upon the thigh. Pressure is gradually increased as the leg is raised. The recreation of hip pain constitutes a positive test and suggests intra-articular or iliopsoas pathology.^14 In the set- ting of fracture, the patient will normally be unable to perform this test due to pain. The supine examination concludes with provocative testing. The FADDIR test is performed by bringing the hip into maxi- mal flexion, adduction, and internal rotation (Fig. 4.6). This test may be accentuated by adding an axial load with downward pres- sure over the knee. Pain in this position constitutes a positive FADDIR test, which may be the most sensitive indicator of FAI. The FADDIR test may also be conducted in the lateral position.
Figure 4.4. The straight leg raise test. Raise straight leg until pain is
[AU6]felt (5A) , then lower the leg 10° and dorsiflex to recreate the pain (5B).
Figure 4.5. Palpation of the adductor tubercle (AT) or the pubic
symphysis (PS) can help localize the source of pain. The pubic sym- physis is directly in the midline, whereas the adductor tubercle is more lateral on either side of the symphysis.
66 Section I • Gross Anatomy
To perform the Patrick/FABER test, have the patient lie in a “figure four” position with the affected ankle lying on the thigh of the unaffected leg and then press on the affected knee to cause sacroiliac joint stress (Fig. 4.7). This stress may manifest itself in different types of pain, each delineating a different pathology. Groin pain implicates the iliopsoas as the origin of pain;^14 lat- eral hip pain suggests lateral FAI; and posterior pain may indi- cate sacroiliac joint pathology. To assess lateral FAI, move the leg
through the full range of flexion and extension while abducted. Pain during this process signifies lateral rim impingement. The Thomas test requires pulling the unaffected leg to the chest, flexed at the hip and knee, while lowering the affected leg to the table (Fig. 4.8). The Thomas test is positive if the patient cannot lower the affected thigh all the way to the table and may signify an iliopsoas contracture. A clicking sound dur- ing the Thomas test implies a labral tear.^10
Figure 4.6. Supine FADDIR test. Bring the hip into maximal flex-
ion, adduction, and internal rotation. This can be done in conjunction with an axial load applied at the knee.
Figure 4.8. The Thomas test. The patient holds the unaffected leg flexed while attempting to lower the affected
leg to the table. An inability to lower the affected leg constitutes a positive test, indicating iliopsoas contracture.
Figure 4.7. The Patrick/FABER test. Have the patient lie in a “figure
four” position, with the affected extremity. Press on the affected knee to elicit pain in the sacroiliac region.
68 Section I • Gross Anatomy
the greater trochanteric bursa is associated with bursitis or IT band contractures. The Ober test consists of three parts: extension, neutral, and flexion (Fig. 4.11). To perform the extension test abduct the affected leg and extend it at the hip while flexing the ipsilat- eral knee. When allowing the leg to fall, note if the leg adducts immediately or if a slight pause or any difficulty in adduction occurs. To perform the neutral test, abduct the leg while the knee is flexed but the hip is in the neutral position, and then allow the leg to fall into adduction. To perform the flexion test rotate the torso to lay both shoulders on the table while both legs are still in the lateral position. Abduct the unaffected leg with the knee fully extended and the hip flexed, and then allow the leg to fall into adduction. In all three tests, the exam- iner abducts the leg in the specific position and then releases the leg. If the leg maintains its abducted position longer than expected, the Ober test is positive. A positive extension Ober test indicates tensor fascia lata contracture, while a positive neu- tral test indicates gluteus medius contracture or tear. A positive flexion test indicates gluteus maximus contracture. To perform the FADDIR test in the lateral position stand behind the patient and place a supporting hand under the patient’s knee while using the other hand to palpate the hip (place the index finger on the anterior portion of the hip with the thumb pointing toward the posterior). Have the patient flex, adduct, and internally rotate the leg to elicit pain or dis- comfort (Fig. 4.12). If any pain or discomfort occurs, the test is thought to be positive. The fi nal part of the lateral examination is the abduction– extension–external rotation test (Fig. 4.13). With the knee fully extended, abduct the leg 30° with no rotation, and flex the hip 10°. Externally rotate the leg and place forward pres- sure on the greater trochanter while bringing the leg from 10 ° fl exion to full extension. If pain occurs with the anterior
pressure and abates in its absence, the test is positive. A posi- tive abduction– extension–external rotation test may indicate anterior acetabular anteversion, iliofemoral ligament strain, or anterior instability of the hip. Patients who are positive for this test should also be assessed for generalized ligamentous laxity.
PRONE
The final component of the examination takes place in the prone position. Most of the tests and examinations in this position are performed as follow-up to earlier positives. Such examinations include palpation of the sacroiliac region, a modified Thomas test, and the Ely test. If indicated, knee and ankle examination may also be performed in this position. If previous examination has produced sacroiliac pain, palpate the three different areas in the sacroiliac region to specify which area is the origin of pain. These three areas are the suprasacroiliac region, the infrasacroiliac region (near the gluteus maximus), and the lower lumbar vertebral spinous processes (L4–5). The next part of the prone examination will help differ- entiate between iliopsoas and rectus femoris contractures. The modified Thomas test is used for the former while the Ely test is used to test the latter. To perform the modified Thomas test have the patient lie in the prone position and see if the pelvis rises off the examination table, indicative of an iliopsoas contracture. The Ely test is performed by flex- ing the leg at the knee until the lower leg is as close to the thigh as possible. If the pelvis and buttocks move upward in this position the test is positive, indicating rectus femoris con- tracture. Because the rectus femoris crosses both the hip and knee joints, the Ely test would only indicate contractures of that muscle as the bending of the knee stretches the rectus femoris across the knee.
Figure 4.10. A & B: Palpation of several points during the lateral examination is important to localize
pain origin. IT, ischial tuberosity; TFL, tensor fascia lata; ITB, iliotibial band; SN, sciatic nerve; TB, greater trochanteric bursa, P, piriformis; GM, gluteus maximus origin; SI, sacroiliac joint.
Chapter 4 • Physical Examination of the Hip 69
Figure 4.12. Lateral FADDIR test. Flex, adduct, and internally ro-
tate the leg while placing one hand on the knee and the other hand on the hip to test for FAI.
Figure 4.13. Abduction–extension–external rotation test. Extend
the knee, abduct the leg 30°, and then externally rotate the leg while placing pressure on the greater trochanter and bringing the leg from 10 ° flexion to full extension.
Figure 4.11. The Ober test is performed with the hip extended (A) ,
in a neutral position (B) , and flexed (C). The knee is flexed in the ex- tended and neutral test, but extended in the flexed test. Additionally, the patient’s shoulders should be on the table during the flexed test.
