eXAMINATION OF THE HIP

clues

· walking aid

· external appliance

· footwear

Look

from front

· stand patient facing you

Deformity

· knees

· feet

Skin

· scars

· circulatory disturbance

Contour

Wasting

· quadriceps

from side

· turn affected side towards you

Deformity

· flexion attitude

· knee (and therefore hip)

· lumbar lordosis

Skin

· scars

from behind

Deformity

· lumbar spine

· buttocks

· popliteal creases

From front

Pelvic tilt

Comfortable

· observe comfortable stance

· check levels of ASIS

· comment on

· pelvis is level / not level

· stance is symmetrical

· knee is flexed, ankle is in equinus

Symmetrical

· attain symmetrical stance

· knees extended

· feet flat on ground

· check levels of ASIS

· comment on

· pelvis is level with symmetrical stance

· pelvis is not level with symmetrical stance

· pelvis is level with asymmetrical stance

· pelvis is not level with asymmetrical stance

· ask for blocks if pelvis not level

· to assess functional leg length discrepancy

Trendelenburg (Apley)

Method

· identify and expose ASISs

· underwear as marker

· stand in front of patient

· place one hand on shoulder of test side

· to prevent leaning over test hip

· use other hand to support hand of opposite side

· to assess downward pressure

· ask patient to stand on test side

· tap on shoulder

· ask to lift opposite leg

· positive test if

· opposite ASIS drops (sound side sags)

· downward pressure exerted on supporting hand

· false negative test

· able to maintain abduction with no abductor function

· fixed abduction contracture

· arthrodesed hip in abduction

· false positive test

· voluntary

· painful abduction (if pain not considered true positive *)

· invalid if

· poor balance

· generalised weakness

· lack of co-ordination or understanding

· costo-pelvic impingement

Interpretation

· true positive test with

1. pain

· painful disorder of hip *

2. pivot

· dislocation or subluxation of hip

· shortening of femoral neck

3. power

· weakness of abductors

Gait

· walk away from you

· walk towards you briskly

· possibilities

· Short

· Trendelenburg (gait or lurch)

· Rigid

· Antalgic

· Weak

· Supratentorial (CNS)

supine on couch

Leg length

· make pelvis square with bed

· attempt to make legs square with pelvis and straight

Legs square and straight

· look below medial malleolus

· no difference in heel height

· compare level of medial malleoli

· difference in level of medial malleoli of (x) cm

· measure leg length

· from ASIS

· to medial malleolus

· leg length difference of (x) cm

Legs not square and straight

Abduction contracture

· comment on contracture

· unable to place legs perpendicular to pelvis because of abduction contracture

· must place other leg in same position

· abduct unaffected hip same degree

· look below medial malleolus

· measure leg length

Adduction contracture

· comment on contracture

· unable to place legs perpendicular to pelvis because of adduction contracture

· must place other leg in same position

· note difficulty

· cannot be done simultaneously

· ideally lift other leg up out of way sequentially but need assistance

· more practical to cross legs sequentially

· look below medial malleolus

· measure leg lengths sequentially

· cross one leg and measure

· cross other leg and measure

Flexion contracture of knee / FFD hip with flexion attitude of knee

· comment on contracture

· unable to place legs straight because of fixed flexion of knee / hip

· must place other leg in same position

· flex unaffected knee over bolster to same degree

· look below medial malleolus

· measure leg length

Valgus knee

· comment on contracture

· unable to place legs straight because of valgus knee

· unable to place other leg in same position

· note difficulty

· must measure component parts of leg

· approximates true leg length

· look below medial malleolus

· measure leg lengths

· from ASIS to tibial tuberosity

· from tibial tuberosity to medial malleolus

Equinus foot

· look below medial malleolus

· difference in effective heel height because of equinus contracture

· measure leg lengths

Galeazzi’s sign

· flex knees to 90^o with hips and ankles at 45^o

· put malleoli at same level

· if unable, due to hindfoot asymmetry

· makes test inaccurate

· note

· level of knees

· parallelism of femora and tibia

· comment

· knees at different levels

· tibias parallel so discrepancy not above knee (ie. in tibia)

· femora parallel so discrepancy not below knee ie. (in femur)

Bryant’s triangle

· identify ASIS with thumb & tip of greater trochanter with forefinger

· comment

· difference in distance between ASIS and GT suggests discrepancy proximal to GT

· assess perpendicular distance between points with fingers of other hand

· comment

· when Bryant’s triangle constructed, perpendicular distance between points is different by (x) fingerwidths

· if reduced, construct Roser-Nelaton’s line

Feel

· along line of inguinal ligament from medial to lateral

· masses (dislocated femoral head, hernias, aneurysms, lymph nodes)

· tenderness (LCFN)

· along posterior greater trochanter

· tenderness (trochanteric bursitis)

Move

Thomas test

· passively flex both knees to 45^o

Lumbar lordosis

· place proximal hand behind back

· ask patient to actively flex unaffected hip and knee to chest

· gently passively maximise flexion

· ask patient to clutch knee to chest

· comment

· lumbar lordosis eliminated

· contralateral flexion range of (x)^o

· do not remove hand throughout test

Extension

· gently extend affected hip passively

· lift heel off bed

· stop when painful

· comment

· fixed flexion deformity of (x)^o

Flexion

· ask patient to actively flex affected hip

· gently passively maximise flexion

· comment

· flexes to (y)^o

· flexion arc of (x)^o FFD to (y)^o

Contralateral extension

· ask patient to hold affected knee

· active extension of unaffected hip

· comment

· contralateral fixed flexion deformity of (x)^o

Special cases

Fixed flexion deformity of knee

· place patient at edge of couch

· when assessing FFD, move heel over edge of couch

· lower heel below level of couch

· to eliminate effect of knee FFD

Painful test

· if test too painful, low threshold for termination

Rotation in flexion

· hip flexed to 90^o

· hold leg with one hand

· hand in popliteal fossa

· leg resting on forearm

· assess pelvis movement with other hand

· palpate contralateral ASIS

· internal rotation

· turn foot out

· external rotation

· turn foot in

· examine contralateral side

Abduction / adduction in extension

· hip and knee extended

· fix pelvis

· abduct unaffected hip so that leg dangles over edge of couch

· do not force painful abduction

· palpate ipsiateral ASIS

· abduction

· adduction

· examine unaffected side

lateral on couch

· lie patient with affected side up

Abductor power

· active abduction

· palpate contraction

· grade power

prone on couch

· avoid with significant pain or FFD

Gluteal bulk

· look at buttock contours

Rotation in extension

· fix pelvis

· place hand across SI jts

· flex knee to 90^o

· internal rotation

· bring foot out

· external rotation

· bring foot in

Special

circulation

· distal pulses

concealed

· groin and perineum

cephalad joint

· lumbar spine

· forward flexion