Hip Examination

Written by: Paul Jones from King's College, London,

Introduction

 

Introduction – Name, Age and Occupation

Wash hands

Explain examination and gain consent

Exposure – Undergarments. Socks and shoes removed

Initial position – Standing

 

Look

 

Gait

  • Pattern

  • Antalgic – patient decreases time spent in weight-bearing stance phase of painful limb

  • Short leg – shoulder dips on side of shorter limb

  • Trendelenburg – waddling caused by failure of hip adductors to elevate pelvis on weight-bearing; caused by weak adductors or inhibition due to pain

 

Trendelenburg's Test – assesses functioning of hip abductors

  • Stand behind patient and ask to stand on one leg for 30 seconds

    • Pelvis should tilt up on side of unsupported leg = Trendelenburg negative (normal)

    • If pelvis tilts down towards unsupported leg = Trendelenburg positive (pathological)

    • True positive Trendelenburg test may be due to L5 radiculopathy, false positive may be due to osteoarthritis

    • Repeat for other leg

Video:  Trendelenberg's Test

 

Inspection

  • With patient facing, assess for

    • A straight stance

    • Pelvic tilt – possibly failure of adductors, short leg etc.

    • Joint asymmetries, deformities – such as limb rotation, fixed flexion etc.

    • Wasting of quadriceps

  • From the side

    • Lumbar lordosis – which suggests fixed flexion hip deformity

  • From behind

    • Scoliosis – primary, or may be secondary to a pelvic tilt

    • Wasting of gluteals

 

Leg Length Discrepancy

  • Position patient comfortably, lying down on back with legs stretched out, pelvis square

  • Measure apparent length – from umbilicus/xiphisternum to medial malleolus

    • In apparent shortening the limbs are not actually different in length, they just appear to be due to pelvic tilt caused by e.g. fixed flexion or adduction deformity of hip

  • Measure true length – from ASIS to medial malleolus

  • Ask patient to flex both hips and bend their knees, with soles of feet on the bed

  • Compare the position of both knees from the side

    • One knee higher than the other suggests tibial shortening

    • One knee behind the other suggests femoral shortening

Video: Leg Length Discrepancy Test

 

Trendelenburg's Test

Weak hip abductors cause pelvis to sag towards unsupported side

Feel

 

Palpation

Check whether they have any tenderness first

  • Tenderness over greater trochanter suggests trochanteric bursitis

  • Tenderness over lesser trochanter suggests iliopsoas strain

  • Tenderness over ischial tuberosity suggests hamstring strain

  • Tenderness over sacroiliac joints

 

Move

 

Have patient positioned lying on their back with the pelvis neutral. Perform alternately on one side then the other, starting with the good side.

 

Flexion (normal 120°)

  • Place left hand underneath the small of the back – to detect whether the patient is compensating with their lumbar spine or pelvis

  • Be careful when flexing the hip of a patient who has had a Total Hip Arthroplasty (THA) as forcing flexion may cause the hip to dislocate

 

Abduction (normal 40°)

  • Rest left hand on patient's pelvis as a bridge between the two ASIS to detect whether patient tilts pelvis to compensate abduction

  • Use right hand to abduct leg until pelvis starts to tilt

 

Adduction (normal 25°)

  • Rest left hand on patient's pelvis as in abduction to detect for false movements

  • Cross the leg being examined over the resting leg

 

Internal rotation at extension (normal 35°)

  • Gently roll leg internally and use foot to determine degree of rotation achieved

 

External rotation at extension (normal 45°)

  • Gently roll leg externally and use foot to determine degree of rotation achieved

 

Internal rotation with hip and knee flexed to 90° (normal 35°)

  • Hold patient's knee with one hand and move foot laterally

  • Compare position of long axis of lower leg to midline

 

External rotation with hip and knee flexed at 90° (normal 45°)

  • Hold patient's knee with one hand and move foot medially

  • Compare position of long axis of lower leg to midline

 

Ask patient to lie on their front

 

Extension (normal 0-20°)

  • Stabilize pelvis with left hand

  • Lift one leg, then the other

Video: OSCE Hip Examination Video

 

Thomas' Test – to assess whether there is a fixed flexion deformity of the hip

  • Position patient lying flat on back

    • Fully flex one hip (this obliterates the normal lumbar lordosis of the spine)

    • Watch extended hip and note any flexion

    • Be careful with patients who have had a THA

    • The most common cause of a fixed flexion deformity of the hip is due to osteoarthritis

Video: Thomas' Test

 

Further examinations and investigations required

 

Orthopaedic examination of knee and back (including straight leg raise and slump test)

Neurological examination of lower limbs

Examination of abdomen

Peripheral vascular examination of lower limb

Appropriate imaging- AP and lateral radiographs of the hip joints

 

Thank patient, explain that you have completed your examination and offer help to dress

 

Common causes of a painful hip in adults

 

Osteoarthritis

Total hip arthroplasty (THA)

Avascular necrosis (AVN)