This document provides information on assessing the hip through history taking, physical examination, and special tests. It outlines the key components of a hip examination including inspection, palpation, range of motion testing, neurological assessment, and special orthopedic tests. Red flags for various medical conditions are also listed. The assessment focuses on evaluating pain characteristics, gait deviations, muscle strength, and tests for structures like the iliotibial band or labrum. Accurate examination of the hip requires analyzing the patient's history and examining both passive and active hip motion.

1. Hip Assessment
Sreeraj S R

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• Introduce yourself
• Obtain consent
• Wash your hands

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Magee DJ. Orthopedic Physical Assessment, 4th Edition. Saunders Elsevier, Missouri. 2006. Chapter 11, Hip. p 607-659

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Assessment
Examination
Active
Movements
Passive
Movements
Muscle strength
Reflexes and
Sensory testing
Leg Length
Special Tests
Dislocation
Fracture
Intra capsular
Disorders
Muscular
Dysfunction
History
Onset,
Provoking &
alleviating
factors,
Quality,
Radiation,
Severity,
Timing
(duration) of
symptoms
Observation
Gait
Posture
Leg length
discrepancies
Muscle
wasting
Muscle wasting

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History
• Onset of the event:
What the patient was doing when it started (active, inactive, stressed), whether the patient believes that activity
prompted the pain, and whether the onset was sudden, gradual or part of an ongoing chronic problem
• Provocation:
Whether any movement, pressure or other external factor makes the problem better or worse. This can also include
whether the symptoms relieve with rest.
• Quality of the pain:
This is the patient's description of the pain. Elicit descriptions of the patient's pain: whether it is sharp, dull, crushing,
burning or tearing along with the pattern, such as intermittent, constant, or throbbing.
• Region and radiation:
Where the pain is on the body and whether it radiates (extends) to any other area.
• Severity:
The pain score (on a scale of 0 to 10). Where a patient is unable to vocalize a score use a scale like Wong-Baker
faces pain scale.
• Time (history):
How long the condition has been going on and how it has changed since onset (better, worse, different symptoms),

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Red Flag Signs
• Cancer:
 Persistent pain at night.
 Constant pain anywhere in the
body.
 Unexplained weight loss (e.g.,
4.5 to 6.8 kg in 2 weeks or less).
 Loss of appetite.
 Unusual lumps or growths.
 Unwarranted fatigue
• Cardiovascular:
 Shortness of breath.
 Dizziness.
 Pain or heaviness in the chest.
 Pulsating pain anywhere in the
body.
 Constant and severe pain in
lower leg (calf) or arm.
 Discolored or painful feet.
Swelling (no history of injury).
Magee DJ. Orthopedic Physical Assessment, 4th Edition. Saunders Elsevier, Missouri. 2006. Chapter 1, Principles and Concepts. p 2

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Red Flag Signs
• Gastrointestinal/Genitourinary:
 Frequent or severe abdominal pain.
 Frequent heartburn or indigestion.
 Frequent nausea or vomiting.
 Change in or problems with bladder
function (e.g., urinary tract
infection).
 Unusual menstrual irregularities.
• Neurological:
 Changes in hearing.
 Frequent or severe headaches with
no history of injury.
 Problems with swallowing or
changes in speech.
 Changes in vision (e.g., blurriness
or loss of sight).
 Problems with balance,
coordination, or falling.
 Faint spells (drop attacks).
 Sudden weakness
Magee DJ. Orthopedic Physical Assessment, 4th Edition. Saunders Elsevier, Missouri. 2006. Chapter 1, Principles and Concepts. p 2

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Pain
Most important reported symptom.
• 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
(involving lateral femoral cutaneous nerve)
• Posterior hip pain: hip extensor and external rotator pathology,
degenerative disc disease, spinal stenosis
• Referred Pain: to knee. hip pathology can be referred to the
knee

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Differentiation of Pain
• Systemic
 Disturbs sleep
 Deep aching or throbbing
 Reduced by pressure
 Constant or waves of pain
and spasm
 Is not aggravated by
mechanical stress
• Musculoskeletal
 Generally lessens at night
 Sharp or superficial ache
 Usually decreases with
cessation of activity
 Usually continuous or
intermittent
 Is aggravated by mechanical
stress
Magee DJ. Orthopedic Physical Assessment, 4th Edition. Saunders Elsevier, Missouri. 2006. Chapter 1, Principles and Concepts. p 5

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Pain Descriptions and Related Structures
Magee DJ. Orthopedic Physical Assessment, 4th Edition. Saunders Elsevier, Missouri. 2006. Chapter 1, Principles and Concepts. p 8

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Personal History
• Occupation and work tolerance
• Diet
• Smoking/alcohol
• Sexual history
• Menopausal history

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Past History
• Trauma
• Any significant medical /surgical illness
• Neurological disorders
• Steroid intake

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Family History
• Autoimmune diseases can cluster in a family
(hypothyroidism, rheumatoid arthritis, SLE).
• Gout, ankylosing spondylitis and psoriasis are examples
of diseases which can be inherited.
• TB in close relative
• Dysplasia
• Metabolic disorders

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Posture
https://mytrainerchris.files.wordpress.com/2013/09/hip_posture.jpg

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Requirements for Normal Gait (ROM)
Initial swing Mid swing Terminal swing
Flexion 200 Flexion 20-300 Flexion 300
Normal Gait (swing phase 40%)
Initial
Contact
Loading
Response
Mid
stance
Terminal
Stance
Pre
swing
Flexion 300 Flexion 300 Extending
to Neutral
Hyper extension
20°
Extension
10°
Normal gait (stance phase 60%)

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Gait deviations
Insufficient Hip flexion at initial
contact:
• Weak hip flexors
• Hip flexor paralysis
• Hip extensor Spasticity
• Insufficient hip flexion ROM
Insufficient hip extension at stance
• Insufficient hip extension ROM
• Hip flexion contracture
• Lower extremity flexor synergy
Circumduction during swing
• Compensation for weak hip flexors
• Compensation for weak dorsiflexors
• Compensation for weak hamstrings
Exaggerated hip flexion during swing
• Lower extremity flexor synergy
• Compensation for insufficient hip
flexion or dorsiflexion

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Gait
• Assessment of the patient’s gait allows the examiner to identify gait
abnormalities due to articular causes (osteoarthritis or inflammation)
and/or muscular causes.
• In antalgic gait, the patient attempts to reduce the load on the hip
that causes the pain.
• In a Trendelenburg gait, weakness of the hip abductors, primarily
the gluteal musculature, causes the pelvis to dip toward the
unaffected side in the stance phase.
• In a compensatory limp with leg shortening, the upper body is
shifted slightly over the leg in the stance phase.

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• Toe in gait
Pt walks with both feet
turned inwards - seen in
Femoral ante version

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• Toe out gait
Pt walks with both feet
turned outwards - seen in
femoral retro version

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PALPATION
• PALPATION GUIDELINES;
 Note differences in tissue tension, muscle tone & texture
 Note differences in tissue thickness
 Identify palpable anomalies
 Define areas of tenderness
 Temperature variations
 Dryness, excessive moisture
 Abnormal sensation
Remember!! Palpate uninvolved part first and painful areas last

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Palpation
Anterior Aspect
• Anterior superior iliac spines : In most patients, these bony prominences are
subcutaneous, being palpated on the sides of the waist.
• Iliac crest : is subcutaneous in most of its course, and both the crests are level with
each other.
• Iliac tubercle : This is felt as a bony prominence on the outer wall of the iliac crest
when palpating posteriorly along the iliac crest.
• Greater trochanter : These can be palpated by the hand moving down from the iliac
tubercles. Normally both the trochanters are on the same horizontal level, but this
relation is disturbed in cases of congenital dislocation of the hip or a fracture of the
hip.

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Palpation
Posterior Aspect
This is best examined with the patient lying on his side.
• Posterior superior iliac spines : These are easily palpable over the dimples which
are just above the buttocks.
• Ischial tuberosity : This is easily palpated when the hips are flexed, when the gluteus
maximus moves upwards and the ischial tuberosity is felt.
• Sacroiliac joint : This joint is not usually palpable, because of the overhanging ilium
and its ligaments.

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Examination
• Active Movements
• Passive Movements
• Resisted Isometric Movements

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Neurological Examination
• Motor Examination • Sensory Examination
Movement Nerve Root
Segments
Hip flexion L2/3
Hip extension L4/5
Hip adduction L2/3
Hip abduction L4/5
Hip Internal rotation L2/3
Hip External rotation L4/5
http://nothinbutapeanut.com/?page_id=577#Lower_Limb_Reflexes

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Special Tests
• Bryant's triangle
• Stork standing test
• Stinchfield's Test
• Fingertip Test
• Thomas test
• Rectus femoris test
• Ely’s Test
• Patrick (Faber) test
• Ober's test
• Piriformis Test
• Test for True Leg Length
• Apparent Leg Length
Discrepancy
• Craig Test
• Scour Test
• Trendelenburg Test
Special Tests Commonly Performed on the Hip;

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Bryant's triangle
The normal response
• Measurements on the affected
and unaffected sides of the
body are equal
If not normal
• The distance between the tip
of greater trochanter and the
junction of 2 perpendiculars
i.e. base of the triangle
measures supra-trochanteric
shortening.http://www.orthopaedicsone.com/display/Main/Bryant's+triangle
https://imueos.wordpress.com/2010/08/23/surface-bony-landmarks/

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Bryant's triangle

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Nelaton's line
• This is a line between the anterior
superior iliac spine and the ischial
tuberosity, with the patient in the
supine position.
Normal
• The tip of the greater trochanter
lies on or below this line.
Abnormal
• If it lies above the line, the femur
has been displaced upwards.
ASIS
Ischeal Tuberosoty

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Stork Standing Test
• purpose: To assess the ability to balance on the ball of the foot.
• equipment required: stopwatch, paper and pencil.
• procedure: Remove the shoes and place the hands on the hips, then position the non-supporting foot against the
inside knee of the supporting leg. The subject is given one minute to practice the balance. The subject raises the
heel to balance on the ball of the foot. The stopwatch is started as the heel is raised from the floor. The stopwatch
is stopped if any of the follow occur:
• the hand(s) come off the hips
• the supporting foot swivels or moves (hops) in any direction
• the non-supporting foot loses contact with the knee.
• the heel of the supporting foot touches the floor.
Rating Score (seconds)
Excellent > 50
Good 40 - 50
Average 25- 39
Fair 10 - 24
Poor < 10
http://www.topendsports.com/testing/tests/balance-stork.htm

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Stinchfield Resisted Hip Flexion Test
• Elicitation: From a supine
position with the knee
extended, the patient is asked
to actively elevate the leg
while gentle manual resistance
is added by the examiner.
• Positive response: a positive
test ellicits pain which is likely
to be associated with an
intraarticular hip pathology
McGrory BJ. Stinchfield Resisted Hip Flexion Test Hospital Physician September 1999 : pp. 41–42.
http://www.hospitalphysician.com/pdf/hp_sep99_rcstinch.pdf

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Fingertip Test
• Assesses contracture
of the hamstrings

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Thomas test
• This test is used to rule out a hip
flexion contracture
• Patient lying supine
• One knee is brought to the
patient’s chest and held there.
• Make sure the lower region of the
lumbar spine remains flat on the
table.
• In the presence of a hip flexion
contracture, the extended leg will
bend at the knee and the thigh will
raise from the table.

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Rectus femoris test
• To test Rectus Femoris
Contracture
• The patient lies supine
• Knees bent over the end or
edge of the examining table.
• The patient flexes one knee
onto the chest and holds it.
• If the test knee extends
slightly, a contracture is
probably present.

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Ely’s Test
• To test tight Rectus Femoris
• The patient lies prone, and
• the examiner passively flexes
the patient's knee
• If the patient's hip on the same
side flexes,
• rectus femoris muscle is tight
on that side and that the test is
positive.
• Femoral nerve stretch

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Ober's test
• To assesses the tensor fasciae latae
(iliotibial band) for contracture
• The patient is 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‘s upper leg
with the knee straight or flexed to 90°.
• The examiner slowly lowers the upper
limb
• if a contracture is present, the leg
remains abducted and does not fall to
the table.

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Patrick (Faber) test
• To assess possible dysfunction of the
hip and sacroiliac joint
• The patient is supine with the hip
flexed, abducted, and externally
rotated and the lateral malleolus of the
test leg above the knee of the
extended, unaffected leg.
• The test may be amplified by pressing
downward on the test knee.
• Pain on back indicates a sacroiliac
joint problem,
• And on anterior hip indicates hip joint
pathology

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Scour Test
• Tests for arthritis, labral tear,
avascular necrosis, osteochondral
defect etc.
• The subject should be in supine
• The examiner passively flexes
and IR/ER hip with abd/add while
applying a compressive force
down femur
• clicking, grinding or pain is
positive sign

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Trendelenburg Test
• A test for weakness of the
gluteus medius muscle during
unilateral weight bearing.
• Therapist is positioned behind
patient to observe the pelvis.
• The patient assumes a
unilateral stance on the test
side extremity.
• A positive sign is indicated by
the pelvis dropping toward the
unsupported limb.

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Girth measurement

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Test for True Leg Length
• Structural
• This test is performed for
unequal leg length, which may
be noted on inspection and
during observation of gait.
To obtain the leg length;
• the examiner measures from
the ASIS to lateral or medial
malleolus.
a) True leg length is measured from the anterior superior iliac spine to the
medial malleolus.
b) A leg length discrepancy is illustrated.

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Apparent Leg Length Discrepancy
• Functional.
• This test should be performed
after true leg length
discrepancy is ruled out.
• The test is performed with the
patient supine, both legs
oriented symmetrically.
• Measure from the umbilicus to
the medial malleolus on both
sides.
a) Apparent leg length is measured from the umbilicus to the medial
malleolus
b) Here, the difference in apparent leg length is due to an asymmetrical
pelvis.

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Segmental True Shortening
(a) The tibia is shorter on the patient’s left. (b) The femur is shorter on the
right.

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Craig Test
• This test is used to measure
the degree of femoral ante
version/retro version.
• The angle that the head and
neck of the femur make with
the perpendicular to the
condyles is called the angle of
femoral version.
• Normal angle of femoral
version is 8-150
a) first palpate the greater trochanter and rotate the leg so that
the trochanter is parallel to the examination table.
b) Now note the angle formed by the leg and the vertical.

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Gait
• Antalgic Gait: Gait VideosAntalgic Gait.mp4
• Stiff Hip: Gait VideosStiff Hip.mp4
• Trendlenburgh gait: Gait Videostrendlenburgh gait.mp4
• BL Trendelenburg gait: Gait VideosBL Trendelenburg
gait.mp4
• Circumductory gait: Gait VideosCircumductory gait.mp4
• High stepping gait: Gait VideosHigh stepping gait.mp4

45. Thank You