HIP JOINT EXAMINATION

VANI VIJAYAN
SCHOOL OF PHYSIOTHERAPY
 EXAMINATION OF
HIP

History • Palpation
Observation • Movements
Inspection • Measurements
• Special tests
 Clinical features of Hip
Pathology
• Pain
• Swelling
• Loss of function
• Limp
• Leg length
discrepancy
 PAIN
Most important reported symptom.
• Site
• Anterior hip pain : arthritis, hip flexor strain, iliopsoas bursitis,
labral tear
• Lateral hip pain: greater trochanteric bursitis, gluteus medius
tear, iliotibial band syndrome (athletes), meralgia paresthetica (an
entrapment syndrome of the lateral femoral cutaneous nerve
syndrome)
• Posterior hip pain DDx: hip extensor and external rotator
pathology, degenerative disc disease, spinal stenosis
• REFERED PAIN: to knee. hip pathology can be referred to the
knee
 The Pain Continues...
• Onset: When did it start?
Hours, days, weeks,
• Character years
Sharp: muscle strain/ tear, fracture
Dull: OA, RA
Achy: OA, RA, AVN
• Radiation
Sciatica can run from the hip, down the back of the thigh, into the
foot
Radiates to the groin can imply inguinal hernia, groin strain, etc.
 Pain:
What were they doing when the pain came on?
• Did they fall?
• fractures, muscle tears, haematomas, etc
• Playing sports?
• Muscle sprain, labral tear, etc
• Prolonged exercise?
• OA
• Gradual vs sudden?
• RA,OA vs. trauma
 Pain:
Do they have any aggravating or relieving factors?
OA gets worse as they day goes on and is relieved by
rest
Muscle tears/sprains may be exacerbated by
movement
RA is worse after prolonged periods of rest
If analgesia works, find out what they take and how
often!
 How does the pain affect their daily
• life?far can they walk?
How
• Difficulty walking up/down stairs?
• Are they still able to do their favourite
hobbies?
• Has their partner noticed their pain limiting
them?
• Are they taking regular analgesia?
 SWELLING

• Site
• Onset
• Duration
• Association with pain
• Progression over time
 LIMP

• Usually noted by kin

• Onset
• Duration
• Association with pain
• Progression
• Ambulatory status
Snapping Hip
 PAST
• Trauma HISTORY
• Tuberculosis
• Surgery around hip
• Skin / hematological disorders
• Neurological disorders
• Connective tissue disorders
• Steroid intake
• Any other significant medical / surgical illness
 PERSONAL
• Occupation andHISTORY
work tolerance
• Diet
• Smoking/alcohol
• Sexual history
• Menopausal history
 FAMILY
• TB in closeHISTORY
relative
• Dysplasia
• Metabolic storage disorders
• Inflammatory arthritis
 GENERAL
•
EXAMINATION
Ht/wt / BM
• External
I
iliac/ inguinal lymph
• Feve
nodes
r
• Stigmata of
• Vital
rheumatoid
signs arthritis/TB
• Pallo • Chest
r expansion
CONTRIBUTING FACTORS FOR HIP DISORDER
 Scanning examination
• To rule out the problems in knee joint, ankle
joint, SI and Lumbar spine
 LOCAL
EXAMINATION
• Observation
• Inspection
• Palpation
• Movements
• Measurements
• Special tests
 Observation
Assessed through anterior, posterior and lateral views
• Posture
• Gait
• Scars
• Sinuses
• Balance
• Deformity
• Symmetry and limb length
• Color and texture of the skin
 GAIT
Limping is the most common
abnormality
 TYPES OF GAIT

Antalgic gait
in painful hip conditions
pt walks with reduced stance phase on
the affected side
 Waddling gait

Body sways from side to

side on a wide base seen
in b/ l DDH,pregnancy
 Trendelenberg gait
In double stance forces
distributed equally over
two hips
In single stance forces
increases 6 fold
Patient lurches on the
affected siade and pelvis
drops on to sound side
 Short limb gait
When the affected limb becomes short
Up and down movement of half of the body
Pt lurches on the affected side with a pelvis
drop on the same side
Short leg gait
 Circumduction gait
- In fixed abduction
deformity or in
hemiparesis the pt moves
his limbs while dragging
his body along with limb
in a semi circle
• Gluteus maximus gait- In
paralysis of gluteus
maximus
• Pt lurches backward
during stance phase
 Quadriceps gait
In quadriceps weakness body collapses-hence the
trunk goes for anterior bending to shift the
vertical vector anterior to the knee to balance
 Toe in-gait
Pt walks with both feet
turned inwards-
seen in femoral
anteversion
 Toe out-gait
Pt walks with both feet turned
outwards- seen in femoral
retroversion
 ATTITUDE OF THE LIMB
• Standing: position of the head
• level of scapulae and nipples curvature of the spine attitude of hip,
knee & ankle
• position of the ASIS-square or oblique
 ATTITUDE OF THE LIMB
• Supine: Position of the
upper limbs
• Lower limbs parallel/rotated
• Exaggerated lumbar lordosis
• Patella facing up/in/out
 INSPECTION FROM
• Scoliosis BACK
• Gluteal muscle
wasting
• PSIS
• Back of iliac crest
• Scars and sinuses
LOOK FOR LIMB LENGTH
DESCREPANCY
Leg length examination – standing
PALPATION
“Confirms the findings of
inspection”
Local temperature Increased
in acute arthritis Joint
tenderness
Anteriorly-2cms below and
lateral to mid- inguinal
point
Posteriorly- junction of medial
2/3 rd and lateral 1/3 rd of a
line joiningGT & PSIS
 Tenderness
• ASIS
• GT
• PSIS
• pubic symphysis
• SI joint
• Ischial tuberosity
 PALPATION
• Femoral artery pulsation
at midinguinal pont
• Palpation of GT:
smooth/irregular
proximal migration
 MEASUREMENT OF DEFORMITY
• Fixed Flexion Deformity
• unilateral -Thomas Test
• The examiner blocks the pelvis by
bringing the contralateral sound hip into
maximal flexion. This eliminates lumbar
lordosis that can be used to compensate
for the hip flexion contracture of the
affected hip.
• The leg to be examined is then brought
into maximal extension with the hip in
neutral adduction and rotation.
 BILATERAL FFD

• Patient in prone position with lower limbs

hangigng out from the edge of the table
• Patient should be able to keep both thighs extended
• Measure the angle between thigh and bed for FFD
 Fixed external & internal rotation deformity

Always remains revealed

Determined by noting the direction of anterior surface

of patella or the toes when the foot is held at right angle
to the leg
 Movements
❖ Flexion (135 deg):sitting ❖ Active SLRT
• For ilio psoas contribution: against
Flex knee and move it towards resistance(supine
the chest without moving the )
opposite leg when patient sits
with the legs hanging on the
edge of the examination couch

•
 Movements
❖ Extension ( 0 to 20 deg)
• For gluteus maximus Hamstring contribution
contribution:

•
 Movements
❖ Abduction ( 0 to 45
deg)

❖ Adduction(0 to 45
deg)
 Movements
❖ External
rotation

90 deg flexion(45 deg)

full extension(45deg)
 Movements
❖ Internal rotation

Internal rotation in 90 deg

flexion(45 deg)

Internal Rotation in full

extension(45 deg)
LIMB LENGTH MEASUREMENTS
 Muscle bulk

Muscle wasting
Leg length examination
 LIMB
• functional length
LENGTH:APPARENT
• patient in straight line and limbs
parellel, defromities not
corrected
• from the fixed midpoint to the
• medial malleolus
shows the compensation that
the pt has developed to
conceal any fixed deformity
• here both limbs should be
kept parallel to each other
• measured from xiphisternum
or umbilicus to medial
malleolus
 TRUE
LENGTH
• anatomical length

•patient in straight line and

deformities corrected and the limbs
are kept in identical position

•measured from the ASIS to medial

malleolus
APPARENT SHORTENING & LENGTHENING

ADDUCTION :APPARENT SHORTENING

ABDUCTION :APPARENT
LENGTHENING
SEGMENT OF TRUE SHORTENING
 SEGMENTAL
SHORTENING:SUPRATROCHANTERIC
NELATON’S LINE
 Bryant’s Triangle

• With the patient lying supine, the

examiner drops an imaginary
perpendicular line from the ASIS of the
pelvis to the examining table.
• A second imaginary line is projected up
from the tip of the greater trochanter of
the femur to meet the first line at a right
angle.
• This line is measured, and the two sides
are compared. Differences may indicate
conditions, such as coxa vara or CDH.
• This measurement can be done with
radiographs, in which case the lines may
be drawn on the radiograph
 Weber – Barstow maneuver
• Measure leg length asymmetry. The
patient lies supine with the hips and
knees flexed
• The examiner stands at the patient’s
feet and palpates the distal aspect of
the medial malleoli with the thumbs.
• The patient then lifts the pelvis from
the examining table and returns to
the starting position.
• Next, the examiner passively
extends the patient’s legs and
compares the positions of the
malleoli using the borders of the
thumbs.
• Different levels indicate asymmetry
 True shortening

Supra trochanteric Infra trochanteric

• Coxa Vara • Malunion
• Perthes • Fracture femur & tibia
• SCFE • Growth arrest from
• Malunited basal # polio
• NOF • Trauma and infective
sequale
• Congenital Coxa Vara
• Arthritis
• Dislocation
TRENDELENBURG
TEST
 Pediatric test for Hip pathology
• Barlow’s test
• Ortolani’s test
• Galeazzi sign
• Telescoping sign
 TESTS FOR
BARLOW’S MANOUVRE DDH
ORTOLANI TEST
• The maneuver is easily performed• by It is performed by an examiner first
adducting the hip while applying light flexing the hips and knees of a supine
pressure on the knee, directing the infant to 90 degrees, then with the
force posteriorly. examiner's index fingers placing anterior
• If the hip is dislocatable - that is, if pressure on the GT gently and smoothly
the hip can be popped out of socket abducting the infant's legs using the
with this maneuver - the test is examiner's thumbs.
considered positive • A positive sign is a distinctive 'clunk'
which can be heard and felt as the
femoral head relocates anteriorly into the
acetabulum: hip
TESTS FOR DDH
Telescoping sign of hip

• Examiner flexes the knee and hip to

90°.
• The femur is pushed down onto the
examining table.
• The femur and leg are then lifted up
and away from the table.
• With the normal hip, little movement
occurs with this action.
• With the dislocated hip, however,
there is a lot of relative movement.
This e
 Galaezzi sign

For assessing unilateral CDH

and may be used in children
from 3 to 18 months of age.
The child lies supine with the
knees flexed and the hips
flexed to 90°. A positive test
is indicated if one knee is
higher than the other
 Nélaton’s Line

• Nélaton’s line is an imaginary

line drawn from the ischial
tuberosity of the pelvis to the
ASIS of the pelvis on the same
side.
• If the greater trochanter of the
femur is palpated well above the
line, it is an indication of a
dislocated hip or coxa vara. The
two sides should be compared.
 TESTS FOR JOINT
CONTRACTURES
FLEXION:THOMAS TEST
 CONTRACTURES
• OBER’S TEST:
• Test for ileo-tibial tract
contracture.
• In lateral decubitus position
knee is flexed to 90 degree
hip is abducted to 40 degree
and pelvis is stabilised.
• limb is gently adducted
towards the examining table
normally the hip adducts and
the limb crosses the midline
 TESTS FOR JOINT
ELY’S TEST
CONTRACTURES
for the contracture of the rectus
femoris
prone position with the knees
extended
passively flex one knee to be tested
normally knee can be flexed fully
in contracted rectus full flexion of the
knee forces the hip into flexion
causing the rise of buttocks
 PHELP’S TEST

• To detect the contracture of gracilis muscle

• Prone position with the knee extended
• Passive abduction to the maximum with the
extended knee
• Knees are then flexed to relax gracilis
• Attempt to further abduct the hip with knee in
flexion
• Further abduction is possible in gracilis
contracture
 PIRIFORMIS TEST

Lateral decubitus position

• hip is flexed to 45 degree
• knee is flexed to 90 degree
• one hand stabilises the pelvis
• other hand pushes the knee to the floor
causing the internal rotation
• Pain-locally-piriformis tendinitis
• Pain-radiates-down-piriformis
syndrome
Special tests
 PATRICK’S
TEST(FABER)
Iliopsoas spasm
SI arthritis
Hip joint
Tend to stress the ipsilateral s-
i joint
•pain is posterior in s-i
arthritis
•pain is anterior in hip arthritis
• The patient lies supine, and the
examiner places the patient’s test
leg so that the foot of the test leg is
on top of the knee of the opposite
leg .
• The examiner then slowly lowers
the knee of the test leg toward the
examining table.
• A negative test is indicated by the
test leg’s knee falling to the table or
at least being parallel with the
opposite leg.
• A positive test is indicated by the
test leg’s knee remaining above the
opposite straight leg.
Flexion and adduction test

This test is used in older children and young

adults as a test for hip disease.
 Foveal Distraction Test
• The patient is in supine. The examiner abducts
the hip to 30° and applies an axial traction to
the leg which reduces intra-articular pressure.
• Relief of pain indicates pathology is
intraarticular
HIP SCOUR / QUADRANT TEST
Hip scour test
Quadrant or scouring test.
He felt the test stressed or compressed the
femoral neck against the acetabulum, or pinched
adductor longus, pectineus, iliopsoas, sartorius or
tensor fascia lata.
The patient lies supine. The examiner flexes and
adducts the patient’s hip so that the hip faces the
patient’s opposite shoulder and resistance to the
movement is felt.
As slight resistance is maintained, the patient’s
hip is taken into abduction while maintaining
flexion in an arc of movement. As the movement
is performed, the examiner should look for any
irregularity in the movement (e.g., “bumps”),
pain, or patient apprehension, which may give an
indication of where the pathology is occurring in
the hip.
LOGROLL TEST

• If its painful, restricted – joint pathology

• Clicking sound – labral tears
FADIR TEST
 Anterior posterior impingement test
Hip dysplasia, SCFE, Femoroacetubular
impingement
• The patient lies supine with the hip flexed to 90°.
• The examiner then medially rotates and adducts the
hip which leads to impingement of femoral neck
against the acetabular rim.
• Forced medial rotation can lead to a labral lesion,
chondral lesion, or both. Pain is a positive sign.
Posterior inferior impingement test
• This test is a test for global acetabular over coverage
(e.g., coxa profunda, coxa protrusion), global
femoral neck offset
• Abnormalities, and posterior acetabular cartilage
damage.
• The patient lies supine with the legs hanging free
over the edge of the bed to ensure maximum hip
extension.
• The examiner then laterally rotates the hip quickly
• Three positive tests that would help to predict
labral pathology:
• 1) pain with the McCarthy hip extension test,
2) painful impingement with hip flexion
abduction and lateral rotation (the anterior
labial tear test),
• 3) inguinal pain on resisted straight leg raise
(Stinchfield resisted hip flexion test).
 McCarthy test
• The patient lies supine on the bed with both hips flexed. The
examiner then takes the good hip and extends it from the
flexed position, first with the hip in lateral rotation, and then
repeats the test with the hip in medial rotation.
• The nontest leg is kept in flexion.
• The test is repeated with the affected hip.
• A positive test would be the reproduction of the patient’s pain.
 Stinchfield resisted hip flexion test
• Position : Supine
• Patient actively elevates the Straight leg to 20 to 30 while PT
applies gentle resistance.
Positive in intra-articular pathology include:
• Labral tear
• Synovitis
• Arthritis
• Occult femoral neck fractures
• Iliopsoas tendinitis / bursitis
• Prosthetic failure or loosening
STINCHFILED RESISTED HIP FLEXION
TEST
 TEST FOR FEMORAL
ANTEVERSION:CRAIG’S TEST
1.Positioned prone 2.Knee
flexed 90 deg
3.One hand over trochanter
4.Other hand is rotating the
leg till the trochanter felt
prominent
5.Angle subtended between
the imaginary vertical to
the long axis of the leg
Craig’s test
 PELVIC STRESS
LATERAL PELVIC TESTS
ANTERIOR PELVIC
COMPRESSION TEST COMPRESSION TEST
FULCRUM
TEST
It tests for the stress
fractures of the shaft of
femur
• Ner examination
• Joint play
Overview on common lesions and
differential diagnosis
DIFFERENTIAL DIAGNOSIS
THANK
YOU