Evaluation of the hip: history and physical examination

Abstract

Examination of a painful hip is fairly concise and reliable at detecting the presence of a hip joint problem. Hip joint disorders often go undetected, leading to the development of secondary disorders. Using a thoughtful approach and methodical examination techniques, most hip joint problems can be detected and a proper treatment strategy can then be implemented based on an accurate diagnosis. The purpose of this clinical commentary is to present a systematic examination process that outlines important components in each of the evaluation areas of history and physical examination (including inspection, measurements, symptom localization, muscle strength, and special tests).

Figure 1.

During stance, the patient with an irritated hip will tend to stand with the joint slightly flexed. Consequently, the knee will be slightly flexed as well. This combined position of slight flexion creates an effective leg length discrepancy. To avoid dropping the pelvis on the affected side, the patient will tend to rise slightly on his or her toes. (Reprinted with permission.)

Figure 2.

In the seated position, slouching and listing to the uninvolved side allows the hip to seek a slightly less flexed position. This position is usually combined with slight abduction and external rotation, which relaxes the capsule. (Reprinted with permission.)

Figure 3.

Leg lengths are measured from the anterior superior iliac spine to the medial malleolus. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 4.

Thigh circumference should be measured at a fixed position, both for consistency of measurement of the affected and unaffected limbs, and for consistency of measurement on subsequent examinations. A. A tape measure is placed from the anterior superior iliac spine (ASIS) toward the center of the patella. B. A selected distance below the anterior superior iliac spine is marked (typically 18cm). C. Thigh circumference is then recorded at this fixed position. (Reprinted with permission)

Figure 5.

A, B. Supine, with the hip flexed 90°, the hip is maximally rotated internally and externally with motions recorded. This method is simple, quick, and reproducible. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 6.

A, B. The C sign. This term reflects the shape of the hand when a patient describes deep interior hip pain. The hand is cupped above the greater trochanter with the thumb posterior and the fingers gripping deep into the anterior groin. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 7.

The classic straight leg raise (SLR) test is performed to assess tension signs of lumbar nerve root irritation. A positive interpretation is characterized by reproduction of radiating pain along a dermatomal distribution of the lower extremity. The SLR may also re-create local joint symptoms or discomfort in stretching of the hamstring tendons. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 8.

With the patient supine, the Patrick (or Faber) test is performed by crossing the ankle over the front of the contralateral knee and then forcing the knee of the involved extremity down on the table. This combination of flexion, abduction, and external rotation stresses the SI joint and when injury or inflammation is present, it markedly enhances symptoms localized to the SI area. This same maneuver can irritate the hip joint as well, but with distinctly different localization of symptoms. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 9.

The log roll test is the single most specific test for hip pathology. With the patient supine, gently rolling the thigh internally (A) and externally (B) moves the articular surface of the femoral head in relation to the acetabulum, but does not stress any of the surrounding extra-articular structures. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 10.

Forced flexion combined with internal rotation is often very uncomfortable and will usually elicit symptoms associated with even subtle degrees of hip pathology. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 11.

Flexion combined with abduction and external rotation similarly is often uncomfortable and may reproduce catching type sensations associated with labral or chondral lesions. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 12.

An active straight leg raise, or especially a leg raise against resistance, generates compressive forces of multiple times body weight across the hip joint. Consequently, this movement is often painful, especially when there is even a mild degree of underlying degenerative disease. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 13.

The patient stands on the affected right leg, lifting the left leg off of the ground. With normal abductor strength, the pelvis should remain level. However, as illustrated here, with abductor weakness, the pelvis drops towards to contralateral side, reflecting a positive Trendelenburg test. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 14.

A,B. Snapping of the iliopsoas tendon may be elicited as the hip is brought from a flexed, abducted, externally rotated position into extension with internal rotation. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 15.

With the patient on their side, snapping of the iliotibial band can sometimes be elicited with flexion and extension of the hip. The Ober test is performed by lowering the knee to the table, assessing for tightness of the abductor mechanism. (Reprinted with permission J. W. Thomas Byrd, M.D.)

Figure 16.

Tenderness to palpation reflects an extra-articular process which, among athletes, may commonly include athletic pubalgia. (Reprinted with permission J. W. Thomas Byrd, M.D.)