OnExam

Inspection

  • Inspect patient in standing and while walking, anteriorly, posteriorly and laterally
    • Gait
      • Stance (60% of gait cycle): heelstrike, foot flat, midstance, push-off
      • Swing (40% of gait cycle)
      • Width of base (mid-heel to mid-heel) should be 2-4 in
      • Waddling or circumduction: hip dislocation, arthritis, labrum tear, femoral acetabular impingement, adbductor weakness all cause pelvis to drop on contralateral side
    • Posture and stance
      • Compare height of iliac crests and gluteal folds
      • Loss of lordosis: paravertebral spasm, hamstring tightness
      • Excess of lordosis: flexion deformity of hip, hip flexor tightness
    • Muscle atrophy, spasm or increased tone
    • Gluteal fold symmetry
    • Illiac crest symmetry
    • Approximate comparative leg length
    • Inspect lumbosacral spine and knees for causes of cervical spine issues
    • Assess for weak hip abductors using the Trendelenberg test

Palpation

While patient standing, note areas of pain, swelling, spasm, muscular atrophy, ligamentous laxity, deformity or crepitus in the following structures:

  • Anterior surface (patient supine)
    • Iliac crests
    • Anterior superior iliac spine (ASIS)
    • Pubic symphysis
    • If hip painful, palpate iliopsoas bursa below inguinal ligament
    • Inguinal structures: NAVEL (Nerve, artery, vein, empty space, lymph nodes)
  • Posterior surface (patient prone)
    • Greater Trochanters
    • Posterior Superior Iliac Spine (PSIS)
    • Sacroiliac Joint
  • Patient semiprone (Lateral surface)
    • Greater trochanter
    • Trochanteric bursa
    • Ischiogluteal bursa
  • Assess for leg length discrepancy (while patient supine) with the true leg length test

Range of Motion

  • Patient supine
    • Flexion (normal = 90-120°), “Bend knee to chest”. Monitor for normal flattening of lumbar lordosis and look for a flexion deformity of hip if contralateral leg flexes or if lordosis increases
    • Abduction (normal = up to 45°) “Move leg out to side”
      • Stabilize contralateral hip. This is a commonly difficult in OA
    • Adduction (normal = up to 30°) “Move leg across other leg”
    • External rotation (normal = 45°) “Flex knee and rotate outward”
      • Note: lower leg and foot turn inward with knee bent. Difficult with OA
    • Internal rotation (normal = 40°) “Flex knee and rotate inward”
      • Note: lower leg and foot turn outward with knee bent. Difficult with OA, most sensitive test
    • Combined Movements - FADIR (Flexion-ADduction-Internal Rotation)
      • Passively flex and internally rotate the hip by bringing the lower leg externally, and bring knee up to opposite shoulder
      • Helps to detect early OA, femoral acetabular impingement, or labral tears
    • Patient prone
      • Extension (normal = up to 30°) “Turn onto stomach, move leg backwards away from table without displacing contralateral leg”

Special Hip Tests

References

  1. Baxter S, ed., McScheffrey G, ed. Toronto Notes: Comprehensive Medical Reference & Review for MCCQE 1 & USMLE 2. 26th ed. Toronto: Toronto Notes for Medical Students Inc; 2010.
  2. Bickley L. Bate’s Guide to Physical Examination and History Taking. 11th ed. New York: Lippincott Williams & Wilkins; 2013.
  3. Hurley K. OSCE and Clinical Skills Handbook. Halifax: Elsevier Canada; 2005.
  4. Pawa J, Lesniak, D., & Lott, A. Approach to the OSCE: The Edmonton Manual of Common Clinical Scenarios. Edmonton Manual; 2011.