2. Trendelenburg sign:
Indication:
To assess the stability of the hip and the ability of the hip abductors (Gluteus medius) to
stabilize the pelvis and the femur.
Method:
The subject is asked to stand only on the ipsilateral LL
Results:
A positive test is evident when the pelvis drops at the contralateral side indicating a
weakness in gluteus medius or an unstable hip on the
affected side (i.e. as a result of hip dislocation).
A negative test is evident when the pelvis levels with the bearing LL.
This test should always be performed on the normal LL first so that the subject
understand what to do.
3. Test for femoral anteversion (forward torsion) angle:
Femoral anteversion or forward torsion is the angle in degrees between the line
passing thru the femoral head/neck and shaft within the transverse plane.
Although the femoral anteversion angle is a measure of twisting of the femoral
shaft that occurs in the transverse plane, it’s also a measure of the deviation of
the femoral head and neck from the frontal plane.
The femoral torsion angle is normally 150 .
The term anteversion is referred to the normal femoral torsion angle.
Actually, the femoral torsion angle is about 30 – 400 at birth, and usually by 6 years
of age, the angle decreases to its normal value (i.e. 150 ) .
4.
5. The torsion angle represents the medial rotation of the femoral shaft that occurs
embryologically.
In fact, the femoral head and neck maintain their position while the femoral shaft twists
medially within the transverse plane.
The result is a femoral shaft that is twisted medially relative to the head and neck of the
femur.
A torsion angle less than 150 is called retroversion (Fig.20B)
while that which is more than 150 is called excessive anteversion (Fig.20C).
Femoral retroversion can result in a toe – out posture and frog-eyes patellae (Fig.21A)
which is actually a lateral rotation of the thigh at the hip joint and it’s a compensation to try
optimally line up the articular surface of the femoral neck with that of the acetabulum.
Excessive femoral anteversion can result in a toe – in posture and squinting patellae
(Fig.21B) or it’s called pigeon toes.
6.
7. A toe – in posture is actually a medial rotation of the thigh at the hip joint and it’s a
compensation to try optimally line up the articular surface of the femoral neck with
that of the acetabulum.
An altered femoral torsion angle either in retroversion or in excessive anteversion
which is uncompensated will result in suboptimal alignment of the femoral head
within the acetabulum.
This can results in decreased shock absorption ability and increased degenerative
changes over time.
Toe – in posture is very common in young children, because the femoral torsion
angle is higher at birth and generally decreases thru childhood.
Excessive anteversion angle is twice as common in girls as in boys.
A common clinical finding of retroversion is a decreased internal rotation ROM at
the affected hip while a decreased external ROM is a common clinical finding of an
excessive anteversion angle.
8. Craig’s / Ryder Test: (Fig.22)
Indication:
To assess the femoral torsion angle.
Method:
The subject lies prone with the knee flexed to 900 .
PTst palpates the posterior aspect of the ipsilateral greater trochanter of the femur.
The hip is then passively rotated internally and externally until the greater trochanter
is parallel with the examining table or reaches it’s most lateral position.
The degree of anteversion can then be estimated based on the angle of the lower leg
with the vertical line.
Results:
An angle of less than 150 proves a positive result for a retroversion angle, and that of
greater than 150 proves a positive result for an excessive torsion angle.
9.
10. Tests for leg – length discrepancies:
In fact there are two types of leg – length discrepancy.
One is called true leg length discrepancy or true shortening which is caused
by an anatomic or structural change in the lower limb resulting from
congenital mal-development (i.e. adolescent coxa vara or coxa valga, CDH,
bony abnormality) or trauma (i.e. fracture).
Because an anatomic short leg results, the spine and pelvis are often
affected, leading to lateral pelvic tilt and scoliosis.
11. The second type of leg length discrepancy is called functional leg length
discrepancy, false shortening, functional shortening
or apparent shortening and is the result of compensation for a change that
may have occurred because of positioning rather than structure.
For example, a functional leg length discrepancy could occur because
unilateral foot pronation.
The examiner should check for a true shortening then for functional
shortening.
12. Before any measure is done for true leg length, the examiner must set the
pelvis square, level, or in balance with the lower limbs which means that the
angle between the pelvis and each lower limb
(pelvic-limb angle) should be equally bilaterally.
(i.e. the angle between the line connecting the two ASISs and the line
connecting each ASIS with the corresponding medial malleolus should be
equal at both sides (Fig.23A, B)the two lower limbs.
The easiest method for positioning the patient depends on whether the
lateral pelvic tilt can be corrected or not.
13. In case of correctable lateral pelvic tilt as in fig.23B,
the subject lies supine, the ASISs are set horizontally, the two lower limbs
are set parallel to each other, and the two feet are 15 -20cm apart.
In case of uncorrectable lateral pelvic tilt as in fig. 24B
(which might be caused by abduction or adduction contracture), the
examiner should set the pelvic – limb angle equally at both sides.
For example if one LL is abducted, the other LL should be set at the same
angle of abduction before making the true leg length tests.
14.
15.
16. To understand the relationship between the pelvic-limb angle on each side
and the accuracy of true leg-length measure, it would be obvious that
abduction of one LL brings the ipsilateral medial malleolus closer to the
corresponding ASIS, and the adduction of one LL brings the ipsilateral medial
malleolus farther from the corresponding ASIS as in Fig. 24A, thus if a
measure of true leg length is done from ASIS to the medial malleolus at one
LL, an inaccurate measure will be obtained because the measured LL will be
shorter than its actual length in case of abducted LL, and will be longer than
its actual length in case of adducted LL.
To summarize, the two lower limbs must be set in a comparable position
relative to the pelvis before making a true leg length test.
17. In North America, leg length measure is usually taken from ASIS to the
medial malleolus; however, these values may be altered by muscle
atrophy or obesity.
Measuring to the Lateral malleolus is less likely to be affected be the
muscle bulk.
Accordingly, a measure from ASIS to the lateral malleolus is more
accurate than measuring to the medial malleolus
18. Now, the measure for true leg length discrepancy is made as follows:
The subject lies supine, the pelvis is set level and square with the two lower limbs.
The initial measure is taken from ASIS to the corresponding lateral malleolus using a
plastic measuring tape (Fig.25).
If leg – length discrepancy is found (i.e. one leg is shorter than the other – positive
test), the examiner should determine where the difference lies.
In other words, Is the difference comes from above the greater trochanter level or
below it.
19. Discrepancy below the trochanteric level.
The discrepancy might be caused by femoral shaft shortening
or tibial shaft shortening
I. Femoral shaft measure:
The examiner now measure the length of one femoral shaft from the greater trochanter of
femur to the lateral knee joint line, then makes the same measure at the other side.
If the test proved negative (i.e. the same length was obtained at both side), then the
examiner must check for the length of tibial shaft.
20. (Fig.25) True leg length is measured from the ipsilateral
ASIS to the medial malleolus
21. Tibial shaft measure:
The examiner measure the length of one tibial shaft from the knee medial joint
line to the medial malleolus, then makes the same measure at the other side.
If the test proved negative (i.e. the same length was obtained at both side), then
the examiner must check for a discrepancy above the trochanteric level.
If either a femoral or a tibial shaft measure is proved positive (i.e. either the
femoral shaft or the tibial shaft at one side is shorter than that at the other side).
The examiner can quickly in another way determine by inspection whether the
cause of discrepancy is from a femoral shaft length or a tibial shaft length.
22. The following test is done.
a. The subjects lies in supine, the hips and knees are flexed with the two
malleoli are lined up equally and symmetrically with one another.
b. The examiner stands at the foot of the subject and look horizontally
at the level of knees, if one knee appears lower than the other, the
tibial shaft is shorter at that side than the tibial shaft at the other
side. If not, the examiner make the next step.
c. The examiner stands at side of the subject and look at the level of
knees again, if one knee projects anteriorly less than the other, the
femoral shaft at that side is shorter than the femoral shaft at the
other side.(Fig.26B)
23. Discrepancy above the trochanteric level.
Discrepancy above the trochanteric level might be caused by
one of the following:
1. Superior hip dislocation
2. Hip Varus deformity (coxa vara)
3. Hip valgus deformity (coxa valga)
24. I. Tests for superior CDH
A. Bryant’s triangle Test: (Fig.27)
Indication:
To assess for a superior CDH.
Method:
Have the subject lie supine.
The examiner drop an imaginary first line from the ipsilateral ASIS of the pelvis to the
examining table, a second imaginary line is projected horizontally from the tip of the
ipsilateral greater trochanter of the femur to meet the first line at right angle.
The length of the second line is then measured and compared with that at the
contralateral side.
25. Results:
Difference between the length of the second lines at both sides indicate a
superior CDH at the side of the shorter line.
The measurement can be done with radiographs (much more accurate), in
which case the lines may be drawn on the radiographic sheet.
26. B. Nelaton’s line Test: (Fig.28)
Indication:
To assess for a superior CDH.
Method:
Have the subject lie supine.
The examiner drop an imaginary line from the ipsilateral ASIS of the pelvis to the
ipsilateral ischial tuberosity.
Results:
If the ipsilateral tip of greater trochanter is felt well above this line, the test proves a
positive, and there might be a superior CDH at that side.
The test is done in comparison with the other side.
28. II. Tests for coxa – vara and coxa – valga deformities.
Introduction:
In normal person, the angle between the line, passing thru the femoral head and neck, and
that passing thru the femoral shaft which is called femoral angle of inclination is normally 150-
160 at birth and decreases to between 1200-1350
in adults (Fig.29A).
If this angle is less than 1200 in an adult, it’s known as coxa – vara (Fig.29B).
If it’s more than 1350, it’s known as coxa – valga (Fig.29C).
29. A. Test for coxa – vara and coxa – valga deformities:
Method:
Have the subject lie in supine, this test is done radiographically by measuring
the angle of inclination at both sides.
Results:
An angle less than 1200 indicates a coxa – vara deformity (Fig.29B),
and an angle greater than 1350 indicates a coxa – valga deformity (Fig.29C).
(Fig. 29) Femoral angle of inclination; Normal (A); coxa vara (B); coxa valga (C)
A B C
30. Hints about the coxa – vara and valga deformities:
In coxa - vara, the greater trochanter appears higher at the pathologic side
compared with the sound side (Fig.30A).
In coxa – valga, the greater trochanter appears lower at the pathologic side
compared with the sound side (Fig.30B).
31. Normal
side
Coxa - vara
side
Normal
side
Coxa - valga
side
(Fig.30)
The greater trochanter appears higher at the coxa – vara side compared with
side (A); The greater trochanter appears lower at the coxa – vara side
compared with the normal side (B)
A B
32. Apparent / functional / false leg – length discrepancy Test:
Indication:
This test is indicated to assess for if:
All the test of true – leg length discrepancies test were proved negative.
There is uncorrectable pelvic obliquity (lateral pelvic tilt).
Method:
Have the subject lie supine,
the two lower limbs are positioned parallel to each other, and the two feet are 15 -
20cm apart.
The examiner either take a measure from the umbilicus ( a soft landmark as in fig.31A)
or xiphoid process ( a bony landmark as in figure 31B) to each medial malleolus at
both sides respectively.
33. Results:
If a comparable measures proved inequality.
There might be an apparent leg – length discrepancy due to a muscular origin (i.e.
adduction or abduction contracture) which makes the pelvic tilted and shows a false
discrepancy in the lower limbs.
Hint about true – leg length discrepancy tests:
A slight difference as much as (1-1.5)cm is considered normal; however.
This difference can still cause symptoms.
34. Joint Play (accessory) motions:
I. long axis traction and inferior glide:
Indication:
To increase hip abduction ROM.
(Fig.31)
A false (apparent) leg – length discrepancy measured from umbilicus to
medial malleolus (A); A false (apparent) leg – length discrepancy measured
from xiphisternum to medial malleolus (B)
A B
35. Open - packed position:
300 of hip flexion, 300 of hip abduction, and a slight external rotation.
Position:
Have the subject lie supine, a strap is applied to the pelvis.
If the subject has NO history of knee pathology, the therapist stands at the feet of the
subject, a belt is wrapped around the back of the therapist and placed anteriorly in the
web spaces of the therapist’s hands (this procedure allows the therapist to apply the
long axis traction and thereby the passive hip inferior glide with the therapist’s body
instead of the his/her upper limbs). The therapist’s hands are then placed around the
subject’s treated limb just above the ipsilateral ankle. (Fig.31A)
If the subject has a history of knee pathology:
The same procedure is done but the subject’s ipsilateral leg is placed at the therapist’s
shoulder, then the therapist’s hands are placed clasped around the anterior aspect of
the subject’s ipsilateral lower thigh. (Fig.31B)
36. Movement:
The therapist applies a long-axis traction force by leaning backward, thereby an
inferior glide by pulling thru the belt.
A B
(Fig.31) Long axis traction and inferior gliding case of free knee pathology
or pain (A); in case of knee pathology and pain (B)
37. Posterior glide: (Fig.32A)
Indication:
To increase the hip internal rotation and flexion.
Position:
The subjects lies supine with the ischial tuberosity of the treated lower limb is
at the edge of the examining bed, the contralateral limb is resting on the floor
or a footstool.
A wedge or a sand bag is placed under the ipsilateral ischial tuberosity to
provide a support to the pelvis.
The Therapist’s stands between the subject’s legs facing the hip being treated.
The hip is maintained in an open – packed position by a strap suspended from
the therapist’s shoulder.
The therapist’s one hand is placed at the posterolateral aspect of the distal
thigh to assist in supporting and maintaining the open – packed position, and
the other hand is placed at the anterior aspect of the proximal part to make
the motion.
38. Movement:
The therapist applies a posterior glide force to the subject’s anterior proximal
thigh.
(Fig.32) Hip posterior glide with the patient lying supine
(A) ; hip anterior glide
with the patient lying prone at the edge of bed (B)
39. Anterior glide: (Fig.32B)
Indication:
To increase the hip extension and external rotation.
Position:
The subject lies prone with the anterior pelvis (i.e. ASISs) is at the edge of the
examining table, the contralateral limb rests on the floor or footstool.
A wedge is placed under the ipsilateral ASIS to provide a support to the pelvis. The
therapist stands between the subject’s legs facing the treated hip.
The ipsilateral hip is maintained in the open – packed position by a strap suspended
from the therapist’s shoulder.
The therapist’s one hand is placed on the anterolateral aspect of the distal thigh, the
other hand is placed posteriorly at the proximal thigh of the treated hip.
Movement:
The therapist applies an anterior glide force to the subject’s posterior proximal thigh.
