Physical Examination of the Hip and Thigh

Inspection/Palpation Anterior View With the patient standing, look for atrophy of the anterior thigh musculature and note the overall alignment of the hip, knee, and ankle.

Posterior View With the patient standing, look for atrophy of the buttock and posterior thigh musculature. Note any pelvic HIP obliquity (one iliac crest lower than the opposite side). Limb-length discrepancy will cause one iliac crest to be lower than the other, but this apparent obliquity can be corrected by placing blocks under the shorter limb. Fixed pelvic obliquity from a spinal deformity cannot SECTION 5 be corrected by this maneuver. Palpate the iliac crests, the posterior iliac spine (deep to the dimples of Venus), and the greater trochanter. A Trendelenburg test can be conducted at this time to determine gluteus medius weakness. For the Trendelenburg test, the patient is instructed to stand ﬁ rst on one leg and then the other for comparison. With normal hip abductor strength, the pelvis will stay level or the side opposite the stance leg will elevate slightly. With abnormal abductor strength in the stance leg, the contralateral iliac crest will drop. This is a positive Trendelenburg test (see page 548).

Gait To assess gait, observe the patient walk across the room. Hip deformities often cause a limp that can range in severity from barely detectable to a marked swaying of the trunk and slowing of gait. Patients with a painful hip joint may have an antalgic gait; that is, they shorten the stance phase on the affected side to avoid placing weight across the painful joint. A Trendelenburg gait, characterized by a lateral shift of the body weight, is seen in patients with weakness of the abductor musculature; this is sometimes primary but is more often secondary to a degenerative disorder of the hip. As the hip joint degenerates and friction within the hip joint increases, it becomes more difﬁ cult for the abductor musculature to level the pelvis during gait. HIP

SECTION 5 Anterior View, Supine With the patient supine, palpate to identify any masses, abnormal adenopathy, or tenderness in the region of the anterior superior iliac spine (ASIS) or greater trochanter. (The examiner is palpating the ASIS in the photograph.) Patients with avulsion of the sartorius or rectus femoris will report tenderness at or directly inferior to the ASIS. Patients with meralgia paresthetica (entrapment of the lateral femoral cutaneous nerve) will report tenderness immediately medial to the ASIS and hypoesthesia over the distal lateral thigh. Patients who report a popping sensation in the hip while ambulating most likely have a thickened iliotibial band that snaps over the greater trochanter as the hip moves into ﬂ exion and internal rotation. Have the patient re-create the snapping and palpate the iliotibial band as it snaps over the greater trochanter. This may be visible (and at times can be seen from across the room).

Lateral View, Side-Lying Place the patient in a side-lying position on the unaffected side to facilitate the examination. Structures in the region of the greater trochanter may be palpated with the patient in the supine position, but examination of this area is easier with the patient lying on the unaffected side. Tenderness to palpation directly over the greater trochanter reproduces pain with greater trochanteric bursitis. Tenderness at the proximal tip of the trochanter may indicate gluteus medius tendinitis. Tenderness at the posterior margin of the trochanter may indicate external rotator tendinitis.

Range of Motion HIP SECTION 5

Flexion: Zero Starting Position To evaluate hip fl exion, the patient is supine on a fi rm, fl at surface with the hip not being examined held in enough fl exion to fl atten the lumbar spine. Flattening the lumbar spine prevents excessive lordosis, which may camoufl age a hip fl exion contracture. Avoid positioning the opposite hip in excessive fl exion, as this will rock the pelvis into abnormal posterior inclination, thereby creating a false- positive hip fl exion contracture. Instead, fl ex the opposite hip to a position where the lumbar spine just starts to fl atten or, more precisely, to a position where the inclination of the pelvis is similar to that of a normal standing posture (ie, the anterior superior iliac spine is inferior to the posterior iliac spine by only 2° to 3°).

Maximum Flexion Maximum hip ﬂ exion is the point at which the pelvis begins to rotate. Normal hip ﬂ exion in adults is 110° to 130°.

Hip Flexion Contracture—Thomas Test The Thomas test is used to evaluate for hip fl exion contracture or psoas tightness. Begin with the patient sitting at the end of the examination table with the legs extending far enough that when the patient lies supine, the table edge will not contact the posterior aspect of the calves. Have the patient then assume a supine position, with the legs hanging off the end of the table. Instruct the patient HIP to pull one hip into maximum fl exion. Observe the contralateral hip to see if it also fl exes off the surface of the table. A normal hip will remain on the table or fl ex very slightly. Greater fl exion indicates psoas tightness or a fl exion contracture. SECTION 5 Abduction and Adduction: Zero Starting Position The Zero Starting Position is with the pelvis level and the limbs at a 90° angle to a transverse line across the anterior superior iliac spines.

Abduction To assess hip abduction, a goniometer is needed. Start with the patient supine and the limbs at a 90° angle to a transverse line across the anterior superior iliac spines. Abduct the leg until maximum abduction is reached, which is when the pelvis begins to tilt, a movement that you can detect by keeping your hand on the patient’s opposite anterior superior iliac spine when moving the leg. Normal hip abduction in adults is 35° to 50°. HIP SECTION 5

Adduction To measure adduction, a goniometer is needed. Start with the patient supine. Flex the opposite extremity to allow adduction of the affected extremity (A). Maximum adduction is reached when the pelvis starts to rotate. If ﬂ exing the opposite extremity is impractical, measure adduction by moving the affected extremity over the top of the opposite limb (B). Normal hip adduction in adults is 25° to 35°.

Internal-External Rotation in Flexion In adults, it is more practical to measure hip rotation with the hips in fl exion; how- ever, this technique should not be used in children or when assessment of femoral torsion or a more precise measurement of hip rotation in a “walking” position is A required. To evaluate hip rotation in fl exion, with the patient supine, fl ex the hip and knee to 90°, with the thigh held perpendicular to the transverse line across the anterior superior iliac spines. Measure internal rotation by rotating the tibia away from the midline of the trunk, thus producing inward rotation of the hip (A). Measure external rotation by rotating the B tibia toward the midline of the trunk, thus producing

HIP external rotation at the hip (B) (see page 1105).

Muscle Testing SECTION 5 Hip Flexors To assess the hip ﬂ exor muscles, ask the seated patient to ﬂ ex the hip upward as you resist the effort with your hand by pushing down on the distal thigh just above the knee.

Hip Extensors To assess the hip extensor muscles, with the patient prone, place the knee in approximately 90° of ﬂ exion and ask the patient to extend the hip as you resist the effort with your hand by pushing against the distal thigh.

Hip Abductors To assess the hip abductors, have the patient lie on the unaffected side. Ask the patient to abduct the hip as you resist the effort with your hand on the lateral aspect of the thigh. Note that hip abductor strength also can be assessed by using the Trendelenburg test. HIP Hip Adductors To assess the hip adductors, with the patient supine, place your hand on the medial aspect of the distal thigh and SECTION 5 ask the patient to adduct the hip as you resist the effort.

Special Tests Trendelenburg Test The Trendelenburg test is used to evaluate hip abductor strength, primarily the gluteus medius. Stand behind the patient to observe the level of the pelvis. Ask the patient to stand on one leg. With normal hip abductor strength, the pelvis will remain level. If hip abductor strength is inadequate on the stance limb side, the pelvis will drop below level on the opposite side, indicating a positive test.

FABER Test The FABER (fl exion-abduction- external rotation) test, HIP sometimes called the fi gure-of-4 test, Patrick test, or Jansen test, is a stress maneuver to detect hip and sacroiliac pathology. With the patient supine, place the affected hip in fl exion, SECTION 5 abduction, and external rotation with the patient’s foot on the opposite knee. Stabilize the pelvis with your hand on the contralateral anterior superior iliac spine and press down on the thigh of the affected side. If the maneuver is painful, the hip or sacroiliac region may be affected. Increased pain with this test also may be a nonorganic fi nding (see page 165).

Log Roll Test With the patient supine, internally and externally rotate the relaxed lower extremity. Pain in the anterior hip or groin, particularly with internal rotation, is considered a positive result. A positive test may indicate acetabular or femoral neck pathology, such as in osteoarthritis or femoral head osteonecrosis. HIP

Piriformis Test

With the patient lying on the unaffected side and the hip and SECTION 5 knee ﬂ exed to approximately 90°, stabilize the pelvis with one hand and use your other hand to apply ﬂ exion, adduction, and internal rotation pressure at the knee, pushing it to the examination table. If a tight piriformis is impinging on the sci- atic nerve, pain may be produced in the buttock and even down the leg.

Scouring Test With the patient supine and the hip fl exed and adducted, use the patient’s knee and thigh to apply a posterolateral force through the hip as the femur is rotated in the acetabulum. Passively fl ex, adduct, and internally rotate the hip while A longitudinally compressing to scour the inner aspect of the joint (A). To scour the outer aspect, abduct and externally rotate the hip while maintaining fl exion during longitudinal compression (B). Pain or a grating sound or sensation is a positive result and may indicate labral pathology, a loose body, or B other internal derangement.

Hamstring Flexibility With the patient supine and the contralateral hip HIP and knee maintained in full extension, instruct the patient to ﬂ ex the hip to 90° and then, while maintaining this position, actively extend the knee SECTION 5 fully. Patients unable to obtain within 10° of full knee extension are considered to have hamstring tightness.