Assessment including history, observation, palpation, examination and special test

1. ASSESSMENT AND
SPECIAL TESTS OF
HIP JOINT

2. Traditional steps
DEMOGRAPHIC DATA
HISTORY
OBSERVATION
PALPATION
EXAMINATION

3. DEMOGRAPHIC DATA
 Name
 Age-
Like congenital hip dysplasia in infants and
osteoporotic femoral neck fractures in elderly
 Gender-
Like congenital hip dysplasia primarily in girls
and Legg-Calve-Perthes disease in boys
 Occupation- affects posture

4. HISTORY

5. History of Present Illness
if trauma involved- mechanism of injury
 did patient land on outside of
hip(e.g.,trochanteric bursitis) or land on or hit
the knee, thus jarring the hip(e.g.,
subluxation, acetabular labrum tear)
 Was the patient involved in repetitive loading
activity(e.g. femoral stress fracture) or
osteoporotic (insufficiency injury)
Time and Duration

6. PAST HISTORY
 Trauma
 Tuberculosis
 Surgery around hip
 Skin /hematological disorders
 Neurological disorders
 Connective tissue disorders
 Steroid intake
 Any other significant medical /surgical
illness

7. PERSONAL HISTORY
Occupation and work tolerance
Diet
Smoking/alcohol/tobacco-
increase the risk of
osteonecrosis
Menopausal history

8. FAMILY HISTORY
TB in close relative
Dysplasia
Metabolic storage
disorders
Inflammatory arthritis

9. PAIN HISTORY
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

10. Pain cont..
 Onset :
 Gradual : RA,OA, etc
 Sudden onset : fractures ,muscle tear, haematoma,
Any fall ? Fracture, haematoma, muscle tear
Playing sports? Muscle sprain, labral tear, etc
 Character
 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.

11. Pain cont..
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
How does the pain affect their daily life?
 How far can they walk?
 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?

12. Diagnostic Clues in Hip Pain
Type of pain Possible Causes
Dull, deep, aching Arthritis, Paget disease
Sharp, intense, sudden, associated
with weight bearing
Fracture
Tingling that radiates Radiculopathy, spinal stenosis,
meraglia parasthetica
Increased pain while sitting with the
affected leg crossed
Trochanteric bursitis
Pain at sitting, legs not crossed Ischiogluteal bursitis
Pain after standing, walking Hip arthrosis
Pain on attempted weight bearing Occult fracture, severe arthrosis
Unremitting, long duration Paget disease, metastatic
carcinoma, severe
arthrosis(occasionally)

13. OBSERVATION

14. OBSERVATION
 Redness
 Swelling-
• Site
• Onset
• Duration
• Association with pain
• Progression over time
 Build of patient
 Tropic changes
 Deformities
 Assistive devices
 Muscle wasting

15. Attitude of limb and Diagnosis
 CDH – Broadening at trochantric level, widening of
the perineum, assymetry of gluteal folds
 Synovitis – mild flexion, abduction, Ext Rotation
,with apparent lengthening
 True arthritis – Flex Adduc Int Rota(FADIR) with or
without true shortening
 Posterior dislocation – FADIR with apparent and
true shortening.
 Anterior dislocation – Flex Abd Ext Rota with
apparent
lengthening
 # NOF, Troch # - Ext Rota(morein troch#)

16. Gait
 Simplest of all definitions “mode of walking”
 Normal gait is rhythmical bipedal biphasic walking in
which the lumbar spine, hip and legs move in unison.

17. Limp
 Any abnormality of normal
rhythmic biphasic walking.
 Usually noted by kin
 Onset
 Duration
 Association with pain
 Progression
 Ambulatory status
Stiffness
Deformity
Limb length disparity
Paralytic disability

18. TYPES OF GAIT
 Antalgic gait
In painful hip
conditions pt
walks with
reduced stance
phase on the
affected side.

19. Trendelenberg
gait
Patient lurches on the
affected side and pelvis
drops on to sound side.

20.  Waddling gait:
Body sways from
side to side on a
wide base seen in
B/L DDH,
pregnancy

21.  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.

22.  Gluteus maximus gait
In paralysis of gluteus maximus, Pt lurches
backward during stance phase.

23.  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.

24.  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

25. Toe in and toe out gait
 Toe in : Pt walks with both feet turned inwards, seen
in femoral anteversion.
 Toe out : Pt walks with both feet turned outward
seen in femoral retroversion.

26. Inspection (front)
 Level of shoulder
 ASIS level
 Symphysis pubis
 Iliac fossa
 Scarpas triangle
 Groin fold
 Front of thigh
 Wasting , swelling
,
sinuses ,abnormal
skin condition,
obvious pulsations

27. Inspection (side)
 Iliac crest/Trochanteric
region
 Lumbar
lordosis/Gluteal
bulge /supra or
infratrochanteric
depression & thigh ms
mass
 Level of tip of
trochanters.

28. Inspection (back)
 Scapula, scoliosis
 Iliac crest / PSIS
(dimple of
venus),Ischial
Tuberosity region
 Gluteal bulge / fold
/back of thigh
 Popliteal folds,
heal
 Wasting/ swelling
/sinus / abnormal
pulsation
/contracture

29. PALPATION

30. PALPATION
 Local temperature
Increased in acute arthritis
 Joint tenderness
Anteriorly-2cms below
and lateral to mid- inguinal
point
Posteriorly- junction of
medial 2/3rd and lateral
1/3rd of a line joiningGT &
PSIS

31. PALPATION
Marking of bony
points.
Tenderness over bony
pt:
 ASIS
 GT
 PSIS
 pubic symphysis
 SI joint
 ischial tuberosity

32. PALPATION
 Iliac crest
 Femoral pulse(vascular
sign of Narah)
 Iliac fossa
 Lymph nodes

33. EXAMINATION

34. SENSORY
EXAMINATION
MOTOR EXAMINATION
NEURAL TENSION
FUNCTIONAL
ASSESSMENT
SPECIAL TESTS

35. SENSORY EXAMINATION

36. MOTOR EXAMINATION
Limb Length Measurement
Musle Girth Assessment
Range of Motion
Manual Muscle Testing

37. Limb Length Measurement
APPARENT LENGTH
MEASURMENTS
TRUE LENGTH
MEASURMENTS
SEGMENTAL LENGTH

38. APPARENT LENGTH MEASURMENTS
 functional length
 patient in straight line and
limbs parellel, defromities
not corrected
 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

39. TRUE LENGTH MEASURMENTS
 anatomical length
 Pt exposed adequately
 Bony points marked with
pencil
 Squaring of the pelvis
 patient in straighat line and
deformities corrected and the
limbs are kept in identical
position
 measured from the ASIS to
medial malleolus

40. MEASUREMENTS
 If True Shortening = Apparent Shortening: No compensation
 True Shortening >apparent shortening: only part of the
deformity is compensated by tilting the pelvis(fixed abduction
deformity)
 True Shortening<apparent shortening: fixed adduction
deformity with no compensation

41. Total length (quick assessment )
Allis or Galeazzi
sign
 Hips flexed up to
60, knees at 90
with feet planted
over the bed.
 Both the knees
should be at the
same level.
 Any disparity in
level indicates limb
length disparity

42. SEGMENTAL LENGTH
 Localization of limb length
disparity
 Leg length
 Thigh length
Supra trochanteric Infra trochanteric

43. Causes of True shortening
Supra trochanteric
 Coxa Vara
 Perthes
 SCFE
 Malunited basal # NOF
 Congenital Coxa Vara
 Arthritis
 Dislocation
Infra trochanteric
 Malunion
 Fracture femur & tibia
 Growth arrest from
polio
 Trauma and infective
sequale

44. Qualitative assessment of shortening
 Midpoint of 2
perpendicular lines
from ASIS and GT
 Ischial tuberosity to
ASIS

45. Qualitative assessment of shortening
 Chiene’s lines
The lines joining the two
ASIS and the two GTs are
parallel to each other
Troch tip to
ASIS

46. Musle Girth/Bulk Assessment
 Circumferential
measurements
 Any muscle wasting
indicates chronic
disease.
 Should be in same
position

47. Musle Girth/Bulk Assessment
Distance taken from tibial
tuberosity__ upward
Muscle Bulk
5 inches VMO
7 cms Vastus Lateralis
9 cms More of Quads less of Hams
11 inches More of Hams less of Quads

48. Range of Motion
 Done using a goniometer
MOVEMENT ROM
(in degrees)
Flexion 0- 120
Extension 0- 30
Abduction 0- 45
Adduction 0- 30
Internal rotation 0- 45
External rotation 0- 45

49. MANUAL MUSCLE TESTING(MMT)
FLEXION
 For ilio-psoas
contribution - Sitting
 Other muscle contribution
Active SLRT against resistance

50. EXTENSION
For gluteus maximus
contribution Hamstring contribution

51. Abduction and Adduction

52. EXTERNAL ROTATION
 In 90 degree flexion  In full extension

53. INTERNAL ROTATION
 In 90 degree flexion  In full extension

54. FUNCTIONAL ASSESSMENT
Functional Tests of Hip
 Squatting
 Going up and down stairs one at a time
 Crossing the legs so that the ankle of one foot rests
on the knee of the opposite leg
 Going up and down stairs two or more at a time
 Running straight ahead
 Running and decelerating
 Running and twisting
 One-legged hop(time, distance, crossover)
 Jumping

56. HARRIS HIP FUNCTIONAL SCALE

57. SPECIAL TESTS
HIP JOINT

58. Tests for hip pathology
PATRICK TEST
HIP SCOUR TEST
CRAIG’S TEST

59. PATRICK TEST
Distinguish between SI
joint and hip joint
pathology.
Also known as
• FABER TEST
• JANSEN’S TEST
• FIGURE OF FOUR
TEST
• BUCKET HANDLE
TEST

60. HIP SCOUR TEST
 examiner passively flexes and adducts the subject’s hip and
places the knee in full flexion.
 The affected limb is placed in adduction and a compression force
is applied and maintained through the femur through a range of
70-140 degrees of hip flexion. The test is repeated in abduction.
 Positive test is a reproduction of the patient's worst pain
 Tests for Hip labrum defect, capsulitis, osteochondral defects,
acetabular defects, osteoarthritis, avascular necrosis and femoral
acetabular impingment syndrome.

61. Craig’s test
 To measure femoral anteversion
 Also called Ryder method for
measuring femoral anteversion
 Normal angle- 8-15 deg.

62. Tests for stability of hip
Telescopy Test
Trendelenburg’s Test
Ortolani’s test
Barlow’s Test

63. Telescopy Test
 Flex the hip to 90
deg,
one hand with the
thumb on ASIS and
the remaining
fingers over the soft
tissue proximal to
femur
 other hand at the
distal femur
 push and pull the
femur

64. Trendelenberg Test
 Assess the ability of the hip
abductors.
 A positive test
demonstrates that the hip
abductors are not
functioning.
 Causes:
• Power : Weakness of the
hip abductors e.g.
myopathy, neuropathy
• Lever : # NOF, Troch# etc
• Fulcrum: Arthritis, RA,
dislocation

65. ORTOLANI TEST
 First flexion the hips and
knees of a supine infant to
90 degrees, then with the
examiner's index fingers
placing anterior pressure
on the greater trochanters
gently and smoothly
abducting the infant's legs
using the examiner's
thumbs.
 A positive sign is a
distinctive 'clunk' which can
be heard and felt as the
femoral head relocates
anteriorly into the
acetabulum

66. BARLOW’S MANOUVRE
 The maneuver is easily
performed by
adducting the hip
while applying light
pressure on the knee,
directing the force
Posteriorly.
 If the hip is dislocatable -
that is, if the hip can be
popped out of socket
with this maneuver -
the test is considered
positive.

67. FOR LABRAL LESIONS
ANTERIOR LABRAL
TEAR TEST
POSTERIOR LABRAL
TEAR TEST

68. ANTERIOR LABRAL TEAR TEST
Starting End point

69. POSTERIOR LABRAL TEAR TEST
Starting End point

70. TESTS FOR MUSCLE TIGHTNESS
OR CONTRACTURES
 OBER’S TEST
 ELY’S TEST
 THOMAS TEST
 RECTUS FEMORIS CONTRACTURE
TEST(KENDALL TEST)
 90-90 STRAIGHT LEG RAISING TEST
 BENT KNEE STRETCH TEST
 TRIPOD SIGN
 PIRIFORMIS TEST(FADIR)
 PHELP’S TEST

71. OBER’S TEST
 Test for ileo-tibial tract contracture.
 Patient in side-lying with test side up. The knee may be
extended or flexed to 90 or 30 deg. The hip is maintained in
slight extension. The test leg is abducted, then allowed to
lower toward the table with the pelvis stabilised.
 normally the hip adducts and the limb crosses the midline

72. ELY’S TEST
 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

73. THOMAS TEST
 patient supine on the
examination table and
holds the uninvolved knee
to his or her chest, while
allowing the involved
extremity to lie flat.
 If the iliopsoas muscle is
shortened, or a
contracture is present, the
lower extremity on the
involved side will be
unable to fully extend at
the hip. This constitutes a
positive Thomas test
 If leg doesn’t lift off the
table but abducts-J sign-
indicative of tight IT Band.

74. RECTUS FEMORIS CONTRACTURE
TEST(KENDALL TEST)
 Pt. supine with knees
bent over edge of
table.
 Pt. flexes one knee
onto chest and the
test leg remains bent
over the table edge.
 The test knee extend
indicates a positive
test.

75. 90-90 STRAIGHT LEG RAISING TEST
 The patient lies supine
with the hips and knees
flexed to 90º and grasps
behind both of his or her
thighs to stabilise the hip
joints, then actively
extends each knee in turn.
 Inability to extend the
knee to within 20º of full
knee extension implies
hamstring muscle
tightness.
 Popliteal angle-if less than
125 deg

76. BENT KNEE STRETCH TEST
 Test for proximal hams.
 Patient in supine, hip and knee of the symptomatic
extremity are maximally flexed, and the knee is then
slowly passively extended by the examiner.
 Pain in hams at ischial origin indicates positive test.

77. TRIPOD SIGN
 For Hams
contracture/tightness
 Pt. seated at edge of table
with both knees flexed to
90 deg., examiner then
passively extends one
knee
 If hams on that side are
tight, patient extends trunk
to relieve tension
 Extension of spine
indicative of positive test.

78. PIRIFORMIS TEST(FADIR)
 Pt. in side lying, hip flexed to 45 degree and knee is
flexed to 90 degree
 one hand stabilises the pelvis and other hand pushes the
knee to the floor causing the internal rotation
 pain locally-piriformis tendinitis
 pain radiates down-piriformis syndrome

79. 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

80. THANK YOU