Clinical examination of the hip

Symptoms arising from the hip region are usually a challenge for the orthopaedic surgeon. The hip joint is surrounded by many layers of muscles, tendons and neurovascular bundles, and so confusion about the origin of the symptoms is not uncommon: whether, that is, they arise from the hip joint itself or from the structures around the hip. Despite the great advances in radiological investigations and in computed tomography and magnetic resonance imaging, it is the clinical examination that reveals the likely origin of the pain in a large proportion of cases. It is the clinical examination that will guide the surgeon towards further diagnostic investigations, directed at the most likely region.
Clinical examination of the hip includes a number of classic clinical manoeuvres as well as some more specific tests for particular pathological problems. It is important that the patient is examined both standing and supine.
EXAMINATION IN THE STANDING POSITION.
Gait.
Gait should be assessed in a space that allows at least three or four gait cycles, which the examiner can observe both from the front and from behind. The doctor should look for a possible abnormal gait pattern, as for example in cases of abductor dysfunction (trendelenburg sign), an antalgic gait, excessive internal or external rotation, leg-length discrepancy and abnormalities in the function of the foot and the ankle joint.
Standing on one leg.
This is essentially the classic trendelenburg test. Standing on one leg allows an assessment of the proprioception of the limb and of the function of the abductors, which hold the pelvis in a balanced position. Standing on one leg, the patient should raise the opposite leg so that the hip and the knee come into 45° of flexion for at least six seconds. This manoeuvre should be carried out on both legs so that a comparison can be made. The test is positive when the pelvis tilts by more than two centimetres.
Hyperlaxity of the joints.
Examination in the standing position should also include an assessment for hyperlaxity in other joints, such as the thumb or the forearm, as well as an assessment of hyperextension at the elbow and the knee.
EXAMINATION IN THE SUPINE POSITION.
Examination of the range of motion.
Examination of the range of motion is an important manoeuvre for determining bony and ligamentous function. Internal and external rotation of the hip is performed passively in the supine and seated positions with the hip flexed to 90°. The seated position ensures that the ischial bones lie perpendicular to the examination couch, which provides adequate stability with the hip flexed to 90° and also creates a reproducible platform for accurate rotational movements. It is also important to determine internal and external rotation with the hip in extension, which is done in the prone position. The degree of the bony as against the ligamentous contribution can be determined from the differences between the flexed and the extended positions. The flexed position releases the medial and lateral parts of the iliofemoral ligament. The dominant restraint to internal rotation, however, both in extension and in flexion, is the ischiofemoral ligament. The range of motion is indicated by a firm end point or by the patient's pain.
Dynamic external rotatory impingement sign.
The dynamic external rotatory impingement sign is similar to the classic MCarthy sign, which when positive is associated with the detection of a click during the manoeuvre. In the supine position the patient is asked to hold the opposite leg in more than 90° of flexion, so as to ensure a neutral position of the pelvis by eliminating the lumbar lordosis. The hip under examination is then brought into 90° of flexion or more and is then passively taken through a wide arc of abduction and external rotation. The test is positive when the patient's pain is reproduced. The dynamic external rotatory impingement sign can also be performed in theatre for direct observation of the abutment of the femoral neck region against the acetabulum.
Dynamic internal rotatory impingement sign.
The dynamic internal rotatory impingement sign is similar to the traditional MCarthy test, which is positive when it is associated with the detection of a click. As in the previous test, elimination of the lumbar lordosis and a neutral position of the pelvis are achieved by having the patient hold the opposite leg in more than 90° of flexion while lying supine. The hip under examination is then brought into 90° of flexion, and beyond, and is passively taken through a wide arc of adduction and internal rotation. The test is considered positive when the patient's pain is reproduced. The dynamic internal rotatory impingement sign can also be performed in the operating theatre.
Palpation.
Palpation should always be carried out during examination of the hip. The patient is asked to locate or to point with a finger to the area of the pain and the examiner then palpates the area to assess bony or musculotendinous regions. The further areas of interest for palpation are the abdomen, the region proximal to the sacroiliac joint, the sciatic notch, the anterior superior iliac spine, the greater trochanter, the ischial tuberosities, the insertion of gluteus maximus and the piriformis tendon.
Flexion/abduction/external rotation.
The flexion/abduction/external rotation (FABER) manoeuvre is known as the Patrick test and is designed to distinguish pain related to the lumbar or sacroiliac region or to the posterior part of the hip, by localising precisely the area in which the pain is reproduced. The examiner brings the leg into 45° of flexion and rotates it externally, while at the same time abducting the leg so that the ankle on the same side rests proximal to the knee of the opposite leg. The passive abduction of the flexed leg is observed and compared with the other side. Posterior pain can usually be localised to the lumbar or sacroiliac region, or it may indicate posterior hip pathology.
Raising the leg with the knee extended against resistance.
This manoeuvre is also known as the Stinchfield test. The patient raises the leg with the knee extended, while lying supine, to 45°. The examiner places a hand just above the knee and presses downwards. This manoeuvre is an assessment of the hip flexors and of the power of psoas, and is a sign of intra-articular pathology, since psoas presses on the labrum during active resistance. The test is positive when it reproduces the patient's pain or shows muscle weakness.
Muscle power.
Muscle power around the hip, including the abductors, adductors, flexors and extensors, should always be examined during the clinical examination of the hip. The examiner applies pressure to the leg and the patient is asked to resist this force. Each muscle group should be graded in the traditional way, on the five-point scale. These manoeuvres can be performed in the supine, seated or lateral position. To examine gluteus medius the iliotibial band should be relaxed by flexing the knee.
Passive rotation of the hip in the supine position.
This manoeuvre is known in English as the “log roll”. With the patient supine and the legs extended on the examination couch, the examiner passively rotates each leg internally and externally and the differences between them are recorded. Any restriction or pain may indicate intra-articular or extra-articular pathology.
Impingement of the posterior rim of the acetabulum.
To assess impingement on the posterior rim of the acetabulum the patient is positioned at the edge of the examination couch so that the legs hang freely at the hip , while the patient draws both legs towards the chest in order to eliminate the lumbar lordosis. The painful leg is then extended below the level of the examination couch, allowing full extension of the hip, and is then abducted and rotated externally. This manoeuvre brings the hip into extension, allowing assessment of the abutment of the posterior wall of the acetabulum and the femoral neck region.
Flexion/adduction/internal rotation.
Flexion/adduction/internal rotation is performed with the patient supine, the thigh being moved passively into full flexion, adduction and internal rotation. Any reproduction of the symptoms in the groin indicates that the manoeuvre is positive, and the degree of flexion and internal rotation reached before the symptoms appear should be noted.
Assessment of the lateral aspect of the hip.
Passive abduction test. The passive abduction test is similar to the Ober manoeuvre with the hip in extension. The patient is placed in the lateral position on the opposite leg, with the shoulders at 90° to the examination table. The examiner stands behind the patient and holds the patient's lower limb, assessing full passive adduction of the hip using the following three manoeuvres:
1. The tensor fasciae latae manoeuvre, in which the hip and the knee are brought into extension in such a way that tension is placed on the tensor fasciae latae tendon with the hip in adduction.
2. The gluteus medius contraction manoeuvre, which is performed with the hip at 0° and the knee in 45°-90° of flexion, so that the iliotibial band is relaxed and tension is placed on gluteus medius with the hip in adduction.
3. The gluteus maximus contraction manoeuvre, which is performed with the shoulders rotated backwards, towards the examination couch, and the hip and the knee in extension, so that tension is placed on gluteus maximus with the hip in adduction. Any restriction of these movements is recorded. A healthy patient should achieve passive adduction that goes beyond the midline of the body,
Assessment in the prone position.
Femoral version manoeuvre (femoral anteversion test). The manoeuvre for assessing femoral version is also called the Craig test, with the patient prone and the knee flexed to 90°. The examiner rotates the leg while palpating the greater trochanter. The examiner rotates the limb so that the lateral aspect of the greater trochanter is as prominent to palpation as possible, thereby placing the femoral head in the centre of the acetabulum. Femoral version (anteversion or retroversion) is calculated by assessing the angle between the axis of the leg and an imaginary vertical line. Femoral version is normally between 8° and 15°. If there is a significant difference in internal rotation the examiner should distinguish between a bony and a ligamentous cause.