Complete Musculoskeletal Exam of the Hip

(English captions by Andrea Matsumoto from the University of Michigan)

To ensure a thorough assessment it is best
to perform the musculoskeletal exam of the

hip in a systematic way.

The following is a suggested order of exam
that incorporates the common techniques for

diagnosing hip injuries.

Begin the hip exam with inspection.

Observe the gait as the patient walks away
and towards the examiner looking for an antalgic

gait, Trendelenburg, or pelvic wink gait types.

From an anterior view assess for alignment
of shoulders, iliac crests, and knees.

Observe body habitus and look for lower extremity
atrophy or skin changes.

From a posterior view again assess for asymmetry,
atrophy, or skin changes.

Look closely for spinal lordosis, scoliosis,
or paravertebral muscle spasm.

To evaluate for lumbar causes of referred
hip pain check back range of motion.

Flexion, extension, lateral flexion to the
left and right, and rotation.

The Trendelenburg test assesses for hip stability.

The examiner sits behind the patient and places
thumbs in the posterior superior iliac spines

and hands on the iliac crests to check for
level height.

The patient then stands on one leg with the
raised unsupported leg flexed at the knee

and hip.

In normal function, the unsupported pelvis
elevates slightly, indicating the gluteus

medius muscle appropriately abducts the supported
hip.

If the pelvis drops on the unsupported side
or remains level, it's considered a positive

Trendelenberg, indicating a weak gluteus
medius or intra-articular pathology in the

supported hip.

The standing flexion test assesses for lumbosacral,
sacroiliac, or pelvic dysfunction.

The examiner stands behind the patient and
places hands on the iliac crests with thumbs

over the inferior notch of the posterior superior
iliac spine.

The patient slowly flexes forward.

If the posterior superior iliac spine moves
more cephalad on one side, the test is positive

indicating dysfunction.
The same maneuver should be repeated with

the patient seated, known as the seated flexion
test.

In the seated test the patient should have
feet flat on the floor, shoulder width apart.

Again the examiner notes the PSIS (posterior
superior iliac spine) positioning on the patient

flexed forward.

If the PSIS moves more cephalad on one side
the test is positive, indicating dysfunction.

The stork test evaluates for a stress fracture
of the pars interarticularis in the lumbar

spine.

The patient places hands on hips and stands
on one leg, and hyper-extends the spine.

Pain in the lumbar region is considered a positive
test.

Next examine the hip in the seated position.

Observe for range of motion with internal
rotation and external rotation.

The fulcrum evaluates for femoral stress fractures.

The examiner places one arm beneath the patient's
femur.

A downward force is then applied to the femur
distally.

Pain is suggestive of a femur stress fracture.

With the patient supine a femoral log roll,
internally and externally rotation the femur,

and a heel strike, an axial force on the femur,
can be performed to assess for possible femur

fractures.

Next assess for any leg length discrepancy.

To prevent loss of leg length due to pelvic
rotation, ask the patient to raise the pelvis

off of table and reposition before fully extending
legs.

You want to measure the distance between the
ASIS (anterior superior iliac spine) and the

medial malleolus and compare the distance from
one side to the other side.

Next evaluate active range of motion.

If pain or limitation exists, repeat with
passive range of motion.

Check straight leg hip flexion, isolating
the rectus femoris muscle.

Then bent knee flexion isolating the
iliopsoas muscle.

Also check resisted strength.

Next check internal rotation, external rotation,
abduction, and resisted adduction.

Palpate anatomic landmarks for tenderness
including the abdomen to evaluate for abdominal

fascial hernia, anterior superior iliac spine,
anterior inferior iliac spine, the iliac crests,

and pubic symphysis.

A passive straight leg raise should be performed
to evaluate for lumbar radiculopathy.

The test is considered positive if the patient
has reproduction of radicular symptoms before

70 degrees of hip flexion.

Hamstring flexibility testing can also be
performed with the hip and knee flexed to

90 degrees, followed by passive extension
of knee.

Full extension is desired, but if not, the
angle short of full extension is recorded.

Thomas' Test assesses for hip flexure contracture.

One hip is maximally flexed to the patient's
chest, flattening the lumbar spine.

If the contralateral leg flexes at the knee
and rises off the table, the test is positive.

Patrick's or Faber Test can be performed
to evaluate for hip and sacroiliac pathology.

One leg is flexed, abducted, and externally
rotated in position resting the foot on the

other knee.

If the leg does not lower into a position
parallel to the exam table, there may be a

hip flexor contracture or protective iliopsoas
spasm.

Pressure on the knee with counter-pressure
on the opposite pelvic brim may elicit pain

at the hip or sacroiliac joint.

In the lateral position, again test active
range of motion and resisted strength for

hip abduction and adduction.

Palpate the greater trochanter of the femur,
the iliotibial band,

and the tensor fasciae latae.

Ober's Test assesses for iliotibial band
syndrome.

With the patient in the lateral position the
knee is supported and flexed to 90 degrees

while the hip is slightly extended and abducted.

When the examiner releases knee support, failure
of the knee to adduct is considered a positive

test.

With the patient prone complete testing of
active range of motion with leg extension.

Palpate anatomic landmarks for tenderness.

The lumbar spine, the sacroiliac joint, the
sacrum, the gluteus maximus muscle, the piriformis

muscle, the sciatic notch, the ischial tuberosity,
and the adductor tubercle of the proximal femur.

The Piriformis Test evaluates for pain from
sciatic nerve irritation caused by piriformis

muscle.

With the patient prone, the knees are flexed
to 90 degrees and the hips are internally

rotated.

Provide resistance against external rotation.

Reproduction of the pain is a positive test.

Ely's Test assesses for rectus femoris spasticity.

With the patient prone, the examiner resists
knee flexion.

If the buttocks raise or a pelvic tilt appears,
it is a positive test.

In concluding the hip exam it is important
to document neurovascular exam.

Here a dorsalis pedis artery, posterior tibial
artery, and capillary refill testing are tested.

Further neurovascular exam may be indicated
by history.

Acknowledgement: The Japanese translation of this video was made as part of Shizuoka-University of Michigan Advanced Residency Training, Education and Research in Family Medicine (SMARTER FM) Project supported by Shizuoka Prefecture and funded by the Community Healthcare Revival Fund.