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1. HIP JOINT ASSESSMENT

2. PARTICIPANTS
• AISHA ABEID
• AMAN TEMBA
• RAPHAEL JOEL
• EVELINE CAIN
• BENSON NJAU
• GISELA FLAVIAN

3. REVIEW OF HIP ANATOMY
• Ball and socket joint of synovial joint
• Connects the pelvic girdle to the lower limb
• Made up of femoral head and acetabulum
• Designed for stability and wide range of
movement
• Covered with a thin layer of hyaline cartilage.

4. • The articular surface of is horse shoe
shaped and is deficient inferiorly
acetabular notch.
• Has a labrum
• It is a circular layer of cartilage which
surrounds the outer part of the acetabulum
making the socket deeper and so helping
provide more stability.
• Acetabular labral tears are a common injury from
major or repeated minor trauma.

6. Iliofemoral ligament
• This is a strong ligament which
connects the pelvis to the femur
• At the front of the joint
• It resembles a Y in shape
• Stabilizes the hip by limiting
hyperextension
LIGAMENTS

7. Cont…..
• Pubofemoral ligament
The pubofemoral ligament attaches the part of the pelvis known as the pubis
(most forward part, either side of the pubic symphysis ) to the femur
• Ischiofemoral ligament
This is a ligament which reinforces the posterior aspect of the capsule
Attaches the ischium to the two trochanters of the femur
• Transverse acetabular ligament
Bridges acetabular notch
• Ligament of the head of femur.
Fat and triangular in shape
Originate from ischial and pubic side of acetabular notch
Inserts at the fovea capitis of femoral head

9. Bursae
• There are four major bursae of the hip that typically be irritated and
inflamed
• One bursa covers the bony point of the hip bone called greater
trochanter bursa.
• Inflammation of this bursa is called trochanteric bursitis
• The another bursa is called iliopsoas bursa, located on the inside
(groin side) of the hip
• Ischiogluteal bursa is located to the deep inferior portion of the
gluteus maximus
• Gluteus Medius bursa is located deep to the distal insertion of gluteus
Medius tendon.

11. Neurovascular supply
• The arterial supply to the hip jt is largely via the medial and lateral
circumflex femoral arteries (branches of profunda femoris artery)
• The artery to the head of femur and the superior & inferior gluteal
arteries provides some additional supply
• The hip joint is innervated primarily by the sciatic femoral and
obturator nerves

13. Muscles
Gluteals
Muscle Origin Insertion Nerve Action
gluteus maximus
outer surface of ilium,
sacrum, coccyx,
sacrotuberous
ligament
iliotibial tract
inferior gluteal nerve
L5, S1,S2
extends & laterally
rotates thigh; through
iliotibial tract, it
extends knee joint
gluteus medius outer surface of ilium
greater trochanter of
femur
superior gluteal nerve
L4,L5,S1
abducts thigh and
medially rotates the
thigh
gluteus minimus outer surface of ilium
greater trochanter of
femur
superior gluteal nerve
L4,L5,S1
abduct thigh and
medially rotates the
thigh

15. Quadriceps
Muscle Origin Insertion Innervation Action
vastus intermedius shaft of femur Patella by means of
patellar tendon to
the tibial tuberosity
by patellar ligament
femoral nerve L2, L3,
L4
extension of leg
Vastus medialis
anterior / lateral
surface of proximal
femur
Patella by means of
patellar tendon to the
tibial tuberosity by
patellar ligament
femoral nerve L2, L3, I4 extends (lower) leg
Vastus lateralis greater troch Patella by means of
patellar tendon to
the tibial tuberosity
by patellar ligament
femoral nerve L2, L3,
L4
extends (lower) leg
Rectus femoris anterior inferior iliac
spine (ilium);
Patella by means of
patellar tendon to
the tibial tuberosity
by patellar ligament
femoral nerve L2 , L3,
L4
extends (lower) leg

17. Hamstrings
Muscle Origin Insertion Innervation Action
Biceps femoris ischial tuberosity
(ischium); shaft of
femur
head (fibula);
lateral condyle
(tibia)
sciatic nerve flexes (lower) leg
Semimembranosus ischial tuberosity
(ischium)
medial condyle
(tibia)
Tibial nerve L5, S1
S2
flexes (lower) leg
Semitendinosus upper end shaft of
femur
medial surface of
tibia
Tibial nerve L5, S1,
S2
flexes (lower) leg

19. Iliopsoas
Muscle Origin Insertion Innervation Action
Iliacus Iliac fossa (ilium); lesser trochanter
(femur)
femoral nerve L2,
L3, L4
flexes thigh
Psoas major T12 – L5 vertebrae lesser trochanter
(femur)
Lumbar plexus
L3_L4
flexes hip and
external rotation
Psoas minor T12 - L1 vertebrae lesser trochanter
(femur)
Lumbar plexus
L3_L4
flexes hip and
external rotation

21. Flexors Extensors Adductors
• Iliopsoas • Hamstrings • Adductor longus
• Sartorius • Adductor Magnus • Adductor brevis
• Tensor fascia lata • Gluteus Maximus • Adductor Magnus
• Rectus femoris • Gracilis
• pectineus • pectineus
• Adductor longus
• Adductor brevis
• Adductor Magnus
• Gracilis

22. Abductors External rotators Internal rotators
• Gluteus medius • Obturator extennus • Gluteus medius
• Gluteus minimus • Obturator internus • Gluteus minimus
• Tensor fascia lata • Piriformis • Tensor fascia lata
• Quadratus femoris
• Gluteus Maximus

24. Bones
• Ilium,
• Ischium
• Pubis,
• Femur which consists of;
 S h a f t
 Greater trochanter
 L e s s e r trochanter
 H e a d of femur
 N e c k of femur
 Condyles and Supracondyles

28. Positions of hip
• Open packed/Resting position:
• 30⁰ flexion, 30⁰ abduction, slight lateral rotation
• Close packed position:
• Extension, medial rotation, and abduction
• Capsular pattern:
• Flexion, abduction, medial rotation

29. HIP PATHOLOGY
• Hip arthritis
• Avascular necrosis
• Femoroacetabular impingement (FAI)
• Trochanteric bursitis
• Hip dislocation
• Hip dysplasia
• Osteoarthritis
• Lebral tear
• Leg calve (perthes disease)

30. Hip arthritis
• Is the deterioration of the cartilage of the hip joint. When cartilage in
the hip is damaged it becomes rough.
• Thinning of cartilage narrows the space between the bones. In
advanced cases bone rub on bone, and any movement can causes
pain and stiffness
• When there is friction at any point between bones it can also lead to
bones spurs

32. Avascular necrosis
• Is the death of bone tissue to lack of blood supply also called
osteonecrosis
• If not stopped this process eventually causes the bones to collapse.
Avascular necrosis mostly occurs in hip and shoulder joints
• Etiologies includes,
i. Trauma
ii. Alcohols
iii. Sickle cell

33. Avascular necrosis

34. Femoral acetabular impingement (FAI)
• Occurs when the femoral head pinches up against the acetabulum.
when this happen, damage to the labrum
• Causing the hip stiffness and pain also arthritis
• Types of FAI
i. Cam
ii. Pincer
iii. combined

36. Trochanteric bursitis
• Is an inflammation (swelling) of the bursa at the outside lateral point
of the hip known as the greater trochanter. When this bursa becomes
irritated or inflamed, it causes pain in the hip
• It can be caused by activities such lying down in one position for the
prolonged period of time, fall or repetitive trauma, excessive walking
or running

38. Hip dislocation
• Occurs when the ball joint of your hip(pops) out of its
sockets(acetabulum), dislocation might be
Posterior dislocation, occurs with axial load on femur, typically with
hip flexed, internally rotated and adducted. Dashboard injury is an
example of axial load on flexed hip.

39. Anterior hip dislocation
• The femoral head is situated anterior to acetabulum, usually caused
by forcefully abduction with external rotation of the thigh and mostly
following a motor vehicle accident or fall

40. Hip dysplasia
• Is the condition where the hips ball(femoral head) and sockets
(acetabulum) are misaligned. The condition occurs when the femoral
head partially or completely slips out of the hip
• Shallowness of acetabulum to support the femoral head
• Causing dislocation of the hip. The exact cause of hip dysplasia is
unknown but several factors are believed to play a contributing role
Abnormal position of the femoral head
A shallow or abnormally shaped acetabulum
Large fetal size, narrow uterus leading to abnormal stress on the hip
joint

41. Hip dysplasia

42. Perthes disease
• Also known as legg-calve-perthes disease, childhood disorders
• Occurs when blood supply to the ball part (femoral head) is
interrupted and bone begins to die

43. osteoarthritis
• Degenerative joint disease. Characterized by degeneration of articular
cartilage leads to fibrillation, fissures, gross ulcerations and finally
disappearance of the full thickness of articular cartilage
• OA the most common form of arthritis and most common joint
disease
• Most of people who have OA are older than age 45
• Causes of osteoarthritis might be aging, overweight, history of injury,
or surgery to a joint

44. HIP PAIN KEY POINTS
Anterior hip pain Lateral hip pain Posterior hip pain
• Arthritis • Greater trochanteric
bursitis
• Degenerative disc
disease
• Hip flexor strain • Gluteus medius tear
• Iliopsoas bursitis • Iliotibial band
syndrome (athletes)
• Spinal stenosis
• Labral tear • Maralgia paresthetical

47. Maralgia paresthetical

48. Piriformis syndrome

49. The femoral triangle
• Wedge shaped area located within the superomedial aspect of the anterior of the
thigh.
• It acts as a conduit for structures entering and leaving the anterior of the thigh
Borders
• Superior border……Inguinal ligament
• Lateral border……medial border of the Sartorius muscle
• Medial border…….Adductor longus
Contents
Femoral nerve…innervates the anterior compartment of the thigh and provides
sensory branches for leg and foot
Femoral artery…responsible for majority of the arterial supply to the lower limb.
Femoral vein
Femoral canal…contains deep lymph nodes and vessels

51. Patient History
During any assessment, the examiner should obtain the following
information from the patient.
1. What is the age of the patient?
• Different conditions occur in different age groups, and range of
motion decreases with age.
• For example, congenital hip dysplasia is seen in infancy,
LeggCalve-Perthes disease is more common in children 3 to 12
years old
2. If trauma was involved, what was the mechanism of injury?

53. 3.What are the details of the present pain and other symptoms
• Hip pain is felt mainly in the groin and along the front or
medial side of the thigh.
• Pain from the lumbar spine may commonly be referred to the
back or lateral aspect of the hip.
• Lateral hip pain may be due to a trochanteric bursitis or tear
of the gluteus medialis tendon, most commonly in older
patients.
• Hip pain may also be referred to the knee or back and may
increase on walking.

54. Cont…
4. Is the condition improving? Worsening? Staying the same?
• Such a question gives the examiner some idea of the present state of the
joint and pathology
5. Does any type of activity ease the pain or make it worse?
• For example, trochanteric bursitis often results from abnormal running
mechanics with the feet crossing midline ( increased adduction)
6. Are there any movements that the patient feels are weak or abnormal?
• For example, in piriformis syndrome, the sciatic nerve may be
compressed, the piriformis muscle is tender, and hip abduction and
lateral rotation are weak.
7. what is the patient’s usual activity or passtime?

55. Cont..
• By listening to the patient, the examiner should be able to tell
whether repetitive or sustained position have contributed to the
problem.
• Also, the examiner can develop some idea of the functional
impairment felt by the patient.
• As the patient comes into the assessment area, the gait should be
observed.
• If the hip is affected;
The weight lowered carefully on the affected side.
The knee bends slightly to absorb the shock.
The length of the step on the affected side is shorter so that
weight can be taken off the leg quickly.

56. During assessment patient should be standing and undressed for proper
observation.
• The following aspects are noted from the anteriorly, laterally, and posteriorly
1. Posture;
NB- Injury to iliopsoas (lateral flexor) may also affect the spine.
• Thus the examiner should watch the effect on the spine and spinal
movements.
2. Ability of the patient to stand on both legs. Two bathroom scales may be
used to check symmetry of weight bearing.
3. Balance.
• Check the patient's proprioceptive control in the joints being assessed.
• Evaluated by asking the patient to balance on one leg starting with
unaffected one later the affected leg.

57. • Also starting with the eyes open, and then with the eyes closed.
4. Observe whether the limb positions are equal and symmetric.
• The position of the limb may indicate the type of injury.
• With traumatic posterior hip dislocation, the limb is shortened, adducted, and
medially rotated, and the greater trochanter is prominent.
• With an anterior hip dislocation, the limb is abducted and laterally rotated
and may appear cyanotic or swollen owing to pressure in the femoral triangle.
• With intertrochanteric fractures, the limb is shortened and laterally rotated.

58. Anterior dislocation
Posterior dislocation

59. 5. Any obvious shortening of a leg.
• May be caused by a spinal scoliosis if is obvious in only one lower limb.
6. Color and texture of the skin.
7. Any scars or sinuses.
8. The patient's willingness to move.

60. Anterior View
• Note any abnormality of the bony and soft tissue contours.
• With many patients, differences in these contours are difficult to detect
because of muscle bulk and other soft-tissue deposition around the hips.
• The examiner must therefore look closely. The same is true for swelling.
Swelling in the hip joint itself is virtually impossible to detect by observation,
and swelling resulting from a psoas or trochanteric bursitis can easily be missed
if the examiner is not carefully observant.
•Lateral View
• From the side, view the contour of the buttock and note any abnormality
(gluteus maximus atrophy).
• In addition, a hip flexion deformity is best observed from this position.
• Compare the two sides and note any subtle differences.

61. Posterior View
• The position of the hip and the effect, if any, of this position on the spine
should be noted.
• For example, a hip flexion contracture may lead to an increased lumbar
lordosis.
• Any differences in bony and soft tissue contours should again be noted.

62. EXAMINATION
Active Movements;
• The active movements are done in such away that the most painful ones are done
last.
• If the history has indicated that repetitive movements, sustained postures, or
combined movements have caused symptoms, these movements should be tested as
well.
• For example, sustained extension of the hip may provoke gluteal pain in the
presence of claudication in the common or internal iliac artery.
Active Movements of the Hip
• Flexion (110° to 120°) - supine
• Extension (10° to 15°) - prone
• Abduction (30° to 50°) - supine
• Adduction (30°) - supine
• Lateral rotation (40° to 60°)

63. • Medial rotation (30° to 40°)
Hip flexion Hip extension

64. Hip Abduction And Adduction
External and
internal rotation

65. Passive Movements
• If the range of movement was not full and the examiner was unable
to test end feel during the active movements, passive movements
should be performed to determine the end feel and passive range of
motion (ROM).

66. Passive Movements of the Hip and Normal End Feel
• Flexion (tissue approximation or tissue stretch)
• Extension (tissue stretch)
• Abduction (tissue stretch)
• Adduction (tissue approximation or tissue stretch)
• Medial rotation (tissue stretch)
• Lateral rotation (tissue stretch)
Resisted Isometric Movements
• The resisted isometric movements are performed with the patient in
supine position.
• Examiner should carefully noting movements which cause pain or show
weakness when the tests are done isometrically, so as to be able to
determine which muscle, if any, is at fault.

67. Resisted Isometric Movements of the Hip
• Flexion of the hip
• Extension of the hip
• Abduction of the hip
• Adduction of the hip
• Medial rotation of the hip
• Lateral rotation of the hip
• Flexion of the knee
• Extension of the knee

68. Flexion and Extension
resistance

69. Adduction and Abduction resistance

70. Lateral and medial rotation
resist.

71. Knee flexion and extension resistance

72. Functional Assessment
• Hip motion is necessary for more activities than just ambulation.
• In fact, more hip ROM is required for daily living activities than is required for
gait; activities such as shoe tying, sitting, getting up from a chair, and picking
things up from the floor all require a greater ROM.
• Ideally, the patient should have functional ranges of;
120° of flexion,20° of abduction, and 20° of lateral rotation.
Functional Tests of the 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

73. Special Tests

74. • Are the tests that the examiner believes are necessary and should be performed
when assessing the hip.
• Most tests are done primarily to confirm a diagnosis or to determine pathology.
• As with all special tests, if the test is positive, it is highly suggestive that the
problem exists, but if it is negative, it does not necessarily rule out the problem.
Common Special tests performed on the hip
Patric’s test
Ober’s test
Sign of the buttock –SLRT
Trendelenburg's Sign
90-90 straight leg raise test

75. Cont..
Leg length test
Thomas test
Rectus femoris test
Abductor/adductor test
• Other tests
• Anterior Labral Tear Test.
• Posterior Labral Tear Test.
• Craig's Test.
• Torque Test.
• Stinchfield Test
• Piriformis Test

76. Test for stability
• Anterior Labral Tear Test
• Patient in supine position.
• examiner takes the hip into full flexion, lateral rotation, and full abduction as
a starting position.
• Then extends the hip combined with medial rotation and adduction.
• A positive test is indicated by the production of pain or the reproduction of
the patient's symptoms with or without a click.
•
• Posterior labral tear test.
• ( A) Starting position. (B) End position.
•

77. Posterior labral tear
• Patient in supine position ,examiner takes the hip into full flexion ,full
adduction and medial rotation
• Then extension, abduction and lateral rotation of the hip
• A positive test is indicated by the production of pain or the
reproduction of the patient’s symptoms with or without a click

79. Patric’s test (FABER Test)/Jansen’s test
• Faber (flexion, abduction, and external rotation) position of the hip when the
patient begins the test.
• The patient in supine,
• The foot of the test leg is on top of the knee of the opposite leg .
• The examiner then slowly lowers the knee of the test leg toward the examining
table.
• A negative test -- knee falling to the table or at least being parallel with the
opposite leg.
• A positive test -- knee remaining above the opposite straight leg. If positive, the
test indicates that the hip joint may be affected, there may be iliopsoas spasm, or
the sacroiliac joint may be affected.

80. Patrick's test (Faber or
Figure Four test)

81. Trendelenburg's Sign
• This test assesses the stability of the hip and the ability of the hip
abductors to stabilize the pelvis on the femur when standing on one leg.
• The patient is asked o stand on one lower limb.
• Negative test - pelvis on the opposite side rises.
• Positive test - pelvis on the opposite side drops.
• The test should always start with the normal side first so that the patient
understands what to do.
Trendelenburg's sign. (A) Negative test.
(B) Positive test

82. Lateral Step Down Manoeuver (Pelvis Drop Test).
• The patient is asked to place one foot on the stool {20 cm (8 inch)}
placed in front of him or her, and stand up straight on the stool on
one foot.
• The patient then slowly lowers the non weight bearing leg to the
floor.
• Negative test – ability to lower the free leg to the floor with the
arms by the side and the trunk relatively erect and no hip
adduction or medial rotation.
• Positive test - On lowering the free leg, the arms abduct and/or
the trunk inclines forward and/or the weight bearing hip adducts
or medially rotate and/or the pelvis flexes forward or rotates
backwards.

84. Torque Test
• The patient lies supine close to the edge of the examining table with the femur
of the test leg extended over the edge of the table.
• The test leg is extended until the pelvis (i.e., the ASIS) begins to move. The
examiner uses one hand to medially rotate the femur to the end of range and
the other hand to apply a slow posterolateral pressure along the line of the neck
of the femur for 20 seconds to stress the capsular ligaments and test the
stability of the hip joint.

85. Stinchfield Test.
• The patient lies supine and flex the hip with the knee straight to 30° of hip
flexion against resistance.
• Hip or groin pain is a positive test for hip pathology.
• Posterior hip pain or back pain indicates lumbar or sacroiliac pathology.
• This test stresses the hip, sacroiliac joint, and lumbar spine.

86. Fulcrum Test of the Hip
• Used to assess for possible stress fracture of the femoral shaft.
• The pt sits with the knees bent over the end of the bed with feet dangling.
• The examiner places an arm under the patient's thigh to act a fulcrum.
• The fulcrum arm is moved from distal to proximal along the thigh as gentle pre-
sure is applied to the dorsum of the knee with the examiner's opposite hand.
• If a stress fracture is present the patient
complains of a sharp pain and express
apprehension when the fulcrum arm is
under the fracture site.
• A bone scan confirms the diagnosis.

87. Muscles and
tendon tests

88. •Thomas Test
• Used to assess a hip flexion contracture, the most common contracture of the hip.
• Patient lies supine while the examiner checks for excessive lordosis, which is usually
present with tight hip flexors.
• Flex one of the patient's hips, bringing the knee to the chest to flatten out the
lumbar spine and to stabilize the pelvis.
• The patient holds the flexed hip against the chest.
• Negative test - the hip being tested (the straight leg) remains on the examining
table.
• Positive test - straight leg rises off the table and a muscle stretch end feel will be felt.
If the lower limb is pushed down onto the table, the patient may exhibit an
increased lordosis.
• If the leg does not lift off the table but abducts as the other leg is flexed to the
chest, it is called the "J" sign or stroke and is indicative of a tight iliotibial band on
the extended leg side.

90. Rectus Femoris Contracture Test (Kendall Test, Method 1).
• pt lies supine with the knees bent over the end or edge of the examining
table.
• flexes one knee onto the chest and holds it.
• Negative test - The angle of the tested knee remains at 90°.
• Positive test - The tested knee extends slightly and a contracture is
probably present.
• The examiner may attempt to passively flex the knee to see whether it will
remain at 90° of its own volition and should always palpate for muscle
tightness when doing any contracture test.
• If there is no palpable tightness, the probable cause of restriction is tight
joint structures (e.g., the capsule) and the end feel will be different (muscle
stretch versus capsular). The two sides should be tested and compared.

92. Ely's Test (Tight Rectus Femoris, Method 2).
• The patient lies prone,
• Examiner passively flexes the patient's knees.
• On flexion of the knee, the patient's hip on the same side spontaneously
flexes, indicating that the rectus femoris muscle is tight on that side and that
the test is positive.
• The two sides should be tested and compared.

93. Ober's Test.
• Assesses the tensor fasciae latae (iliotibial band) for contracture.
• The in the side lying position with the lower leg flexed at the hip and knee for
stability.
• The examiner then passively abducts and extends the patient‘ upper leg with
the knee straight or flexed to 90°, Then slowly lowers the upper limb.
• Positive test - the leg remains abducted and does not f to the table.
• When doing this test, it is important to extend the hip slightly so that the
iliotibial band passes over the greater trochanter of the femur.
• To do this the examiner stabilizes the pelvis at the same time stop the pelvis
from "falling backward. The original test is done with the knee flexed

94. • However, the iliotibial band has a greater stretch placed on it when the
knee is extended.
• Also, when the knee flexed during the test, greater stress is placed on
the femoral nerve.
• If neurological signs (i.e., pain, paresthesia) occur during the test, the
examiner should cosider pathology affecting the femoral nerve.
• Likewise tenderness over the greater trochanter should lead the
examiner to consider trochanteric bursitis.

95. • (A) Knee straight. (B)
The hip is passively
extended by the
examiner to ensure
that the tensor fasciae
latae runs over the
greater trochanter.
• (C) Test done with the
knee flexed. The
original test position

96. Piriformis test
• About 15% of the population, the sciatic nerve, all or in part, passes
through the piriformis muscle rather than below it.
• These people are more likely to suffer from this relatively rare condition,
“piriformis syndrome”.
• Patient is in the side lying position with the test leg uppermost. The pt
flexes the test hip to 60° with knee flexed.
• The examiner stabilizes the hip with one hand and applies a downward
pressure to the knee.
• Positive test - If the piriformis muscle is tight, pain is elicited in the muscle.
If the sciatic nerve is pinched by this muscle, pain results in the buttock,
and sciatica may be experienced by the patient.
• Resisted lateral rotation with the muscle on stretch (hip medially rotated)
can cause the same sciatica.

98. Adduction Contracture Test
• This test is designed to test the length of the adductor muscles (adductor
longus, brevis and magnus, and pectineus) of the hip.
• The pt lies supine with the ASISs level.
• Normally, the examiner can easily "balance" the pelvis on the legs. This
"balancing" implies a line joining the ASIS is perpendicular to the two lines
formed by the straight legs.
• If a contracture is present, the affected leg forms an angle of less than 90⁰ with
the line joining the two ASISs.
• If the examiner then attempts to "balance" the lower limb with the pelvis, the
pelvis (i.e., ASIS) shifts up on the affected side or down on the unaffected side,
and balancing is not possible.

99. Abduction Contracture Test
• Used to test the length of the abductor muscles (gluteus medius and
minimus) of the hip.
• The pt lies supine with the ASISs level.
• Positive test - the affected leg forms an
angle of more than 90° with a line joining
each ASIS.
• If the examiner then attempts to balance
the lower limb with the pelvis, the pelvis
(i.e., the ASIS) shifts down on the affected
side or upon the unaffected side, and
balancing is not possible.
Abductor
and
Adductor
Contracture
tests

100. 90-90 Straight Leg Raising Test (Hamstrings Contracture, Method 1).
• The supine patient flex both hips to 90° while the knees are bent.
• The patient then grasps behind the knees with both hands to stabilize the
hips at 90° of flexion. Then actively extends each knee in turn as much as
possible.
• For normal flexibility in the hamstrings, knee extension should be within
20° of full extension. If the hamstrings are tight, the end feel will be muscle
stretch.
• Nerve root symptoms may also result, as this positioning is similar to the
slump test done in supine lying instead of sitting.

101. • 90-90 straight leg
raising test.

102. Sign of the Buttock (SLRT)
• The patient lies supine and the examiner performs a straight leg raising test.
• If there is limitation on straight leg raising, the examiner flexes the patient's knee
to see whether further hip flexion can be obtained.
• If hip flexion does not increase, the lesion is in the buttock or the hip, not the
sciatic nerve or hamstring muscles.
• There may also some limited trunk flexion.
• Causes of a positive test include;
• –Ischial bursitis,
• –A neoplasm,
• –An abscess in the buttock, or –Hip pathology.

103. Hamstrings Contracture Test (Method 2).
• The pt is sit with one knee flexed against the chest to stabilize the pelvis and the
other knee extended.
• Then pt attempts to flex the trunk and touch the toes of the extended lower limb
(test leg) with the fingers. The test is repeated on the other side, then a comparison
is made.
• Negative test - The pt is able to at least
touch the toes while keeping the knee
extended.
• Positive test – inability to touch toes
with fingers, an indication of tight
hamstrings on the straight leg.
Test for hamstring
tighmess (method 2).
(A) Negative test. (B) Positive test.

104. Tripod Sign (Hamstrings Contracture,
Method3).
• The patient is seated with both knees flexed to 90° over the edge of the
examining table.
• The examiner then passively extends one knee.
• Positive test - patient extends the trunk to relieve the tension in the hamstring
muscles.
• The leg is returned to its starting position, and the other leg is tested and
compared with the first side and comparison is made.
• The examiner must be aware that nerve
root problems (stretching of the sciatic nerve)
can cause a similar positive sign, although
the symptom will be slightly different.
(radiating pain)

105. Test for leg length
• There are two types of leg length discrepancy
1. True leg length discrepancy/true shortening; This is caused by anatomical or
structure change in the lower leg resulting from congenital maldevelopment eg.
adolesce coxa vara, congenital hip dysplasia or trauma.
2.Functional or apparent leg discrepancy/shortening
• The patient lies supine with the ASISs level.
• To obtain the leg length, the examiner measures from the ASIS to lateral or medial
malleolus.
• The Examiner place the flat metal end of the tape measure distal to the ASIS and
pushed up against it. The tape measure is then straighten down to the medial
malleolus. There the readings are taken. The procedure is repeated in the second leg
• Positive test – difference in length is greater than 1 to1.5 cm. however, this difference
can still cause symptoms.

106. • Leg length discrepancy.

107. Neurological Tests
• Integrity of the Nervous System:
• This is tested if the clinician suspects that the symptoms are arising from
the spine or from a peripheral nerve.
• Dermatomes/Peripheral Nerves:
• Light touch and pain sensation of the lower limbs are tested by the use of
cotton wool and pinprick respectively.
• Knowledge of the cutaneous distribution of the nerve roots (dermatomes)
and peripheral nerves, enable the clinician to distinguish the sensory lose
due to the root lesion from that due to peripheral nerve lesion.

108. • Dermatomes
around the
hip

109. Sensory distribution of peripheral nerves around the hip. A)
Anterior view. (B) Posterior view.

110. Myotomes:
L2 hip flexion,
L3 – knee extension,
L4 – foot dorsiflexion and inversion,
L5 – extension of the big toe,
S1 – eversion foot, contract buttock, knee
flexion,
S2 – knee flexion, toe standing,
S3-4 – muscles of the pelvic floor, bladder
and genital funtion

111. ReflexTest
• This is the test for tendon reflex.
• L3/4 knee jerk
• S1 ankle jerk

112. Neurodynamic Test
• Neurodynamic tests are performed to test the mechanical movement of the
neurological tissues and to test their sensitivity to mechanical stress or
compression.
• These neurodynamic tests along with relevant history and decreased range of
motion are considered by some to be the most important physical signs of disc
herniation, regardless of the degree of disc injury.
• This is the test for the mobility of the nervous system.
• The tests are carried out in order to ascertain the degree to which neural tissue is
responsible for the production of the patient’s symptom(s).
• These tests are;
 Straight-Leg-Raising Test
 Passive Neck Flexion
 Prone Knee Bend
 Slump

113. Straight Leg Raising Test
• Also known as Lasegue's test. The straight leg raising test is done by the
examiner with the patient completely relaxed. It is one of the most
common neurological tests of the lower limb.
• It is a passive test, and ~ach leg is tested individually with the normal leg
beg tested first. With the patient in the supine position, the hip medially
rotated and adducted, and the knee extended, the examiner flexes the hip
until the patient complains of pain or tightness in the back or back of the
leg.
• If pain is primarily in the leg, it is more likely that the pathology causing the
pressure on neurological tissues is more lateral.
• If the pain is primarily back pain, it is more likely a disc herniation or the
pathology causing the . Pressure is more central.

114. Cont….
• Disc herniation or pathology causing pressure between the two extremes are
more likely to cause pain in both areas.
• The examiner then slowly and carefully drops t he leg back (extends it) slightly
until the patient feels no pain or tightness. The patient is then asked to flex
the neck so the chin is on the chest, or the examiner may dorsiflex the
patient's foot, or both actions may be done simultaneously.
• Most commonly, foot dorsiflexion is done first.
• Both of these maneuvers are considered to be provocative or sensitizing tests
for

115. Straight leg raising.
(A)Radicular symptoms are
precipitated on the same side
with straight leg raising.
(B)The leg is lowered slowly
until pain is relieved. The foot is
then dorsiflexed, causing a
return of symptoms

116. Passive Neck Flexion
• The neck flexion movement has also been called Hyndman's sign, Brudzinski's
sign, Lidner's sign, and the Soto-Hall test.
• Neck flexion may be done by itself as a passive movement (passive neck
flexion).
• Tension in the cervicothoracic junction is normal and should not be
considered a production of symptoms.
• If lumbar, leg, or arm symptoms are produced, the neurological tissue is
involved.
• The ankle dorsiflexion movement has also been called the Bragard's test.
• Pain that increases with neck flexion, ankle dorsiflexion, or both indicates
stretching of the dura mater of the spinal cord or a lesion within the spinal
cord (e.g., disc herniation, tumor, meningitis).
• Pain that does not increase with neck flexion may indicate a lesion in the
hamstring area (tight hamstrings) or in the lumbosacral or sacroiliac joints.

117. Slump Test.
• This is the most common neurological test for the lower limb.
• The patient is seated on the edge of the examining table with the legs
supported, the hips in neutral position (i.e no rotation, abduction, or
adduction), and the hands behind the back.
• The examination is performed in sequential steps.
• First, the patient is asked to "slump" the back into thoracic and lumbar flexion.
The examiner maintains the patient's chin in the neutral position to prevent
neck and
• The examiner then uses one arm to apply over pressure across the shoulders to
maintain flexion of the thoracic and lumbar spines.

118. • While this position is held, the patient is asked to actively flex the
cervical spine an head as far as possible (i.e., chin to chest).
• The examiner then applies overpressure to maintain flexion of
three parts of the spine (cervical, thoracic, and lumbar using the
hand of the same arm to maintain over pressure in the cervical
spine.
• With the other hand, the examiner then holds the patient's foot in
maximum dorsiflexion. While the examiner holds these positions
the patient is asked to actively straighten the knee much as
possible.

119. (F) Examiner extends
patient's knee and
dorsiflexes foot with
the neck flexed.
• (E) Examiner carefully
applies overpressure to
cervical spine.
(G) Patient extends head.
If symptoms are
reproduced at any stage,
further sequential
movements are not
attempted.

120. • Sequence of subject
postures in the slump test.
(A) Patient sits erect.
(B) Patient slumps lumbar
and thoracic spine while
examiner holds head in
neutral.

121. (C) Examiner pushes
down qn shoulders
while patient holds
head in neutral. (D)
Patient flexes head. (E)
Examiner carefully
applies overpressure to
cervical spine. (F)
Examiner extends
patient's knee and
dorsiflexes foot. (G)
Patient extends head. If
symptoms are
reproduced at any
stage, further sequential
movements are not
attempted

122. Palpation
• During palpation of the hip and associated structures, the examiner should note
any of the following;
Tenderness,
Temperature,
Muscle spasm, or
Any other signs and symptoms that may indicate the source of pathology.
• Note tenderness of bone {the greater trochanter may be tender due to
trochanteric bursitis and the ischial tuberosity due to ischiogluteal bursitis}
• Ligament,tendon,tendon sheath and nerve {the sciatic nerve can be tender with
muscle spasm of the piriformis muscle}
• Tenderness around the inguinal area may be due to iliopsoas bursitis.

123. Pediatric Tests for Hip Pathology
• Orthopedic tests are commonly performed in newborns to detect
problems, especially congenital dislocation of the hip (CDH) or
developmental dysplasia of the hip (DDH) that covers more than
congenital problems, which may be amenable to conservative
treatment if caught early.
• These tests include;
• Ortolanis Sign Barlows Test
• Galeazzi/Allis Sign –3 18 month of age
• Telescoping Sign/Piston/Dupuytren test

124. Ortolani's Sign
• This test can determine whether an infant has a congenital dislocation
of the hip.
• With the infant supine, the examiner flexes the hips and grasps the
legs so that the examiner's thumbs are against the insides of the
knees and thighs and the fingers are placed along the outsides of the
thighs to the buttocks.

125. • With gentle traction, the thighs are abducted, and pressure is applied
against the greater trochanters of the femora.
• Resistance to abduction and lateral rotation begins to be felt at
approximately
• Positive test - The examiner may feel a click, clunk, or jerk, which indicates
that the hip has reduced; in addition, increased abduction of the hip is
obtained.
• The femoral head has slipped over the acetabular ridge into the
acetabulum, and normal abduction of 70° to 90° can be obtained.
• This test is valid only for the first few weeks after birth and only for
dislocated and lax hips, not for dislocations that are difficult to reduce.

126. • The examine should take care to feel the quality of the click. Soft
clicks may occur without dislocation and are though to be caused by
the iliofemoral ligament's clicking over the anterior surface of the
head of the femur as it laterally rotated.
• Soft clicking usually occurs without the prior resistance that is seen
with dislocations. By repeated rotation of the hip, the exact location
of the click can be palpated. However, the test should not be
repeated too often because it could lead damage of the articular
cartilage of the femoral head.
• As with all clinical tests, if the test is positive, it is highly suggestive
that the problem (i.e., congenital dislocation of the hip) exists, but if

127. it is negative, it not necessarily rule out the
problem

128. Cont..
• (A) In the newborn, the two hips can be equally flexed, abducted, and
laterally rotated without producing a "click." (B) Ortolani's sign.
• Barlow's Test
• This test is a modification Ortolani's test used for developmental dysplasia
of the hip.
• The infant lies supine with the legs facing the examiner.
• The hips are flexed to 90°, and the knees are fully flexed.
• Each hip evaluated individually while the examiner's other hand steadies
the opposite femur and the pelvis. The examiner's middle finger of each
hand is placed over greater trochanter, and the thumb is placed adjacent
the inner side of the knee and thigh opposite the Iesser trochanter.

129. Cont..
• The hip is taken into abduction while examiner's middle finger applies forward
pressure hind the greater trochanter.
• Positive test - The femoral head slips forward into the acetabulum with a click,
clunk, jerk, indicating that the hip is dislocated.
• This part of the test is identical to Ortolani's test.
• The examiner then uses the thumb to apply pressure backward and outward on
the inner thigh.
• Positive test - The femoral head slips out over the posterior lip of acetabulum and
then reduces again when pressure removed, the hip is classified as unstable.
• The hip is not dislocated but is dislocatable.
• Then the procedure is repeated for the other hip.
• This test may be used for infants up to 6 month age. It should not be repeated too
often because it may result in a

130. Cont..
• dislocated hip as well as articular damage to the head of the femur.
• Galeazzi Sign (Allis or Galeazzi
• Test)
• The test is good only for assessing unilateral congenital dislocation of
the hip or unilateral development dysplasia of the hip and may be
used in children from 3 to 18 months of age.
• The child lies supine with the knees flexed and the hips flexed to 90°.
• Negative test – The knees get the same level.
• Positive test - One knee is higher than the other.