WEBVTT

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

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

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hip in a systematic way.

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

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diagnosing hip injuries.

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Begin the hip exam with inspection.

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

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gait, Trendelenburg, or pelvic wink gait types.

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

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

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

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

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

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

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The Trendelenburg test assesses for hip stability.

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

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

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

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and hip.

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

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medius muscle appropriately abducts the supported
hip.

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

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

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supported hip.

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

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

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over the inferior notch of the posterior superior
iliac spine.

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The patient slowly flexes forward.

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

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indicating dysfunction.
The same maneuver should be repeated with

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the patient seated, known as the seated flexion
test.

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

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

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flexed forward.

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

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

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spine.

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

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Pain in the lumbar region is considered a positive
test.

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Next examine the hip in the seated position.

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

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The fulcrum evaluates for femoral stress fractures.

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

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A downward force is then applied to the femur
distally.

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Pain is suggestive of a femur stress fracture.

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

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

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fractures.

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Next assess for any leg length discrepancy.

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

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off of table and reposition before fully extending
legs.

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

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

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Next evaluate active range of motion.

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

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

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Then bent knee flexion isolating the 
iliopsoas muscle.

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Also check resisted strength.

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

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

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

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and pubic symphysis.

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

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

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70 degrees of hip flexion.

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

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90 degrees, followed by passive extension
of knee.

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

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Thomas' Test assesses for hip flexure contracture.

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

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

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

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

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other knee.

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

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hip flexor contracture or protective iliopsoas
spasm.

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

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at the hip or sacroiliac joint.

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

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hip abduction and adduction.

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

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and the tensor fasciae latae.

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Ober's Test assesses for iliotibial band
syndrome.

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

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while the hip is slightly extended and abducted.

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

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test.

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

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Palpate anatomic landmarks for tenderness.

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

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

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

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muscle.

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

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rotated.

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Provide resistance against external rotation.

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Reproduction of the pain is a positive test.

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Ely's Test assesses for rectus femoris spasticity.

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With the patient prone, the examiner resists
knee flexion.

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

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

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

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Further neurovascular exam may be indicated
by history.

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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.