(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.