Clinical Examination of the Hip

History

Question 1 – Is the pain attributable to hip disorders?

• Any back pain, radiating pain, numbness, or tingling in the legs?
• Any pelvic pain, radiating to the groin, temporal relation to menstrual cycle?
• Pain with coughing/straining (hernias, muscle strains)?
• Is the thigh and knee pain referred from the hip?
• Is a hip condition causing secondary pain in the pelvis or low back?

Question 2 – Is the hip pain mechanical in nature?

Rule out non-mechanical pain and causes: fever, chills, night pain, rest pain, steroid use, alcoholism, trauma.

Clues to mechanical causes:

• Pain with prolonged standing and walking – dysplasia (rim loading, labral degeneration, abductor fatigue), foveal impingement, cartilage defects, abductor dysfunction
• Pain with sitting, getting in and out of a car – intra-articular impingement. Inability to squat or sit cross-legged suggests intra- or extra-articular causes of impingement.
• Groin pain – intra-articular: anterior labral tear from FAI or anterior dysplasia, synovitis, joint irritation. Extra-articular: subspine impingement, iliopsoas tendinitis, bursitis, snapping, adductor strain. Non-hip: hernia, inguinal lymphadenopathy, upper lumbar radiculopathy, pelvic referred pain.
• Lateral hip pain – commonly referred from all intra-articular hip conditions, anterolateral hip impingement, gluteus medius and minimus tendinopathy, abductor fatigue/insufficiency, trochanteric bursitis, ITB irritation and snapping.
• Posterior hip pain – posterior hip impingement, posterior dysplasia, piriformis syndrome, other sciatic entrapment, GT impingement, LT impingement, proximal hamstring tear, pudendal nerve entrapment, G. max tendinitis, referred pain from SI joint and lumbar spine.

Common to dysplasia and impingement are lateral hip, thigh, or knee pain and labral tear. On exam, internal rotation at 90 degrees of flexion is increased to 30–60 degrees in dysplasia or type 2 FAI and restricted with type 1 impingement.

Impingement sign is positive in both as well as in most hip conditions. Lack of pain in other directions and lack of rest pain differentiate mechanical pain from diseases like AVN, synovitis, and transient osteoporosis.

Impingement usually causes pain and damage with flexion activities like squatting, deep flexion sitting, and getting in and out of a car. The pain can be in the groin, thigh, or knee. About 20% have pain with running.

Dysplasia usually causes lateral hip pain after prolonged standing and walking.

Physical Examination

The basic hip exam starts with a standing exam, checking gait and strength. External snapping is best reproduced by the patient while standing.

Standing Exam (from behind)

• Spine for deformity, flexibility, aggravation of hip pain, and tenderness; quick neuro exam routinely
• Leg length assessment — most accurate while standing with feet flat, hips and knees extended, palpating iliac crest height on both sides
• Check for thigh and calf atrophy; continue observing during gait exam
• Palpation of posterior iliac crest, SI joint, sciatic notch, ischial tuberosity for posterior hip pain (piriformis syndrome, gluteus maximus enthesopathy, hamstring tears, pudendal nerve entrapment)

Gait

• Antalgic – shortened single limb stance time on the painful side
• Trendelenburg – from abductor insufficiency, unstable head, varus neck, or muscle weakness. Can be an adaptation to decrease hip pain, but waddling increases shear stress on hip cartilage and valgus stress on the knee.
• Circumduction – typically in unilateral weakness but can compensate for decreased joint forces and coronal plane contractures; also with iliopsoas tendinitis
• Short swing – hip stiffness, flexion deformity, lesser trochanteric impingement
• Short limb – shoulder dip in single leg stance on the short side; toe walking on the shorter side and knee flexion on the long side are other compensations
• Intoeing – increased femoral anteversion, anterior dysplasia, LT impingement
• Outtoeing – slipped epiphysis, femoral and acetabular retroversion. Anterior dysplasia makes outtoeing gait uncomfortable in the groin. Lesser trochanter impingement causes gluteal pain and shortened stride length.
• Neurological exam – heel walking, toe walking, single leg hop on each limb tests strength, spasticity, coordination, and overall limb function efficiently

Supine Hip Exam

It is very important to square the pelvis in the supine position on a firm exam table. The following tests can be done in a minute or two.

• Palpate anterior crest, ASIS, inguinal canal, pubic tubercle, symphysis, adductor origin for upper groin pain. Check with coughing and straining for hernias, resisted sit-up test for sports hernia, resisted adduction for adductor strain.
• Straight leg raise – checks for back pain, sciatica, hamstring tightness, and posterior apprehension for posterior dysplasia. Impinging hips usually have tight hamstrings.
• Hip flexion in neutral – bring hip to extension, bend the knee, flex the hip slowly in neutral rotation and abduction looking for range, bony block, and groin pain. Check for flexion deformity of the opposite hip (Thomas test). AIIS impingement and anterior capsular or labral irritation can cause groin pain.
• Flexion internal rotation (FIR) – hold the hip and knee at 90 degrees and neutral abduction/adduction. Allow external rotation if necessary to reach 90 degrees of flexion. Carefully internally rotate looking for pain and the endpoint before the pelvis starts to move. Healthy range is 20–30 degrees.
  • Restricted motion with a clear bony block and pain at end range is classic FAI
  • Pain through most of the range of FIR can be FAI, but also occurs in other hip conditions
  • Increased FIR with pain at end range is typical of anterior dysplasia
  • Resisted internal rotation in 90 degrees of flexion tests gluteus medius and minimus strength; pain suggests strain or tear
• Impingement sign – forced flexion, adduction, and internal rotation pinch the anterior labrum causing groin pain in anterior impingement, anterior dysplasia, and most hip conditions. Posterior hip pain with this test suggests posterior dysplasia, instability, or posterior labral and chondral damage from contrecoup forces. Flexing and extending the hip during impingement testing compresses the anterior labrum in different locations.
• Posterior apprehension – pushing the flexed thigh posteriorly
• FABER – lateral pain and restricted range support lateral FAI; posterior pain suggests SI joint problems
• Hyperextension external rotation – tests posterior impingement and anterior apprehension
• Internal snapping test from FABER position to extension, adduction, and internal rotation; resisted flexion beyond 90 degrees for iliopsoas tendinitis; piriformis stretch pain; hamstring activation at 45 and 90 degrees; LT and GT impingement tests; Ober's test — performed based on symptoms

Lateral Position Exam

Used to isolate gluteus medius for strength testing and to palpate the greater trochanter, trochanteric bursa, and gluteal insertion. Anterior apprehension can be more effective with addition of an anterior translatory force to the femoral head.

Prone Position Exam

Used to check femoral version and anterior apprehension.