Alignment Physical Examination of the Hip
• Pelvic obliquity o True LLD (leg length discrepancy) . Varus/valgus femoral neck, congenital/traumatic/growth disturbances of femur/tibia o Functional/apparent LLD . Lumbosacral junction contractures (scoliosis), posttraumatic pelvic deformity, abd/adduction contractures of the hip, flexion contracture of the knee o Direct measurement . ASIS (anterior superior iliac spine) to medial malleolus, umbilicus to medial malleolus o Block method (quantify) o Visual method (quantify) o Abduction contracture – long (functional LLD) o Adduction contracture – short (functional LLD) o Femoral (supine exam) vs tibial (prone exam) true discrepancy o Hip flexion contracture (functionally short) Gait
• Trendelenburg/abductor lurch • Weak abductors, hip OA • Gluteus maximus lurch
Inspection
• Surface anatomy: anterior, lateral, posterior, medial
Palpation
• Anterior o ASIS – avulsion fracture o Pubic symphysis/rami – o Iliac crest – apophysitis, hip fractures in elderly, symphysitis pointer in soccer players o AIIS (anterior inferior iliac crest) o Hip joint (2 cm lateral and distal – avulsion of rectus to femoral pulse) o Lateral femoral cutaneous o Femoral shaft – stress fracture nerve (percussion) – Tinel’s: o Quadriceps – contusion, meralgia paresthetica hematoma with later myositis o Lesser trochanter – avulsion of ossificans, strain iliopsoas, snapping iliopsoas o Sartorius – strain near ASIS o Femoral nerve/artery/verin/lymphatics (lateral to medial)
Palpation (Continued) Physical Examination of the Hip
• Lateral o Greater trochanter – Greater trochanteric pain syndrome: trochanteric bursitis, gluteus medius bursitis
• Posterior o PSIS (posterior superior iliac spine) o Ischial tuberosity – avulsion/tendonitis o SI joint – ankylosing spondylitis o Piriformis tendon – tendonitis o Sciatic notch o Gluteus maximus o Sacrum o Hamstrings – strain o Coccyx – coccydynia
• Medial o Adductors (groin pulls)
• Metal on metal total hip o Palpable masses, femoral nerve weakness
Range of Motion
• Prone hip extension • Hip flexion (110°+) • Abduction in extension (45°) • Adduction in extension (30°) • IR/ER in flexion (35°/45°)
Manipulation
• Muscle testing o Abductors – gluteus medius/minimus o Adductors – longus, brevis, magnus, gracilis o Flexors – iliopsoas, rectus, sartorius o Extensors – gluteus maximus, hamstrings
Sensation
• Lateral femoral cutaneous nerve (meralgia paresthetica/anterior total hip)
Special Tests Physical Examination of the Hip
• Hip joint – impingement sign/test (flexion/adduction/internal rotation) • Joint contractures o Thomas – flexion contracture: . supine, knees to chest, extend hip to neutral
o Ober’s – IT band, trochanteric bursitis, snapping hip, IT band tendonitis: . lateral, flex knee to 90°, abduct hip to 40°, then adduct hip to exam table
o Ely – rectus femoris contracture: . prone, knees extended, flex one knee, positive if hip involuntarily flexes
o Tripod – hamstrings contracture: . seated, knee flexed to 90°, extend knee, positive if hip involuntarily extends
• Tendinitis o Resisted active contraction of the suspected muscle-tendon unit can cause pain o Passive stretching of the suspected muscle-tendon unit can cause pain o Piriformis test . Lateral, knee 90°, hip 45°, adduct/internally rotate hip toward exam table to stretch the piriformis muscle • Pelvic stress o Patrick/FABER – SI joint pathology: . flexion, abduction, external rotation in supine position • Other o Stinchfield’s – hip joint, hip flexor, painful total hip: . supine, active straight leg raise with or without resistance