Hip examination

Bahaa Ali Kornah-Al-Azhar Un. Cairo. EGYPT
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

CLINCIAL HIP
EXAMINATION
Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt

Keytothespine
Task at hand...
l How to examine a patient
SYSTEMATIC APPROACH

Systematic Approach
l Steps
_ Components
1
2
3
4
5

Systematic Approach
l Miss a Step

 Avoid lack of a systematic approach in
your clinical practice.
 Develop your own routine that works best
for you but don’t stray too far from the
norm.
 Just as important do not jump around and
get the order of the hip examination out of
sync.


It’s not “What you do” but
“How you do it” that counts.
Don’t forget the 5 P’s.

Few important points
before examination proper
Introduce
yourself
consent
exposure
Female
attendant

Professional attitude
Polite
Gesture
Dress
Handling
Mobile in
vibration mode.

HISTORY
SYMPTOMS / CHIEF COMPLAINTS
 PAIN
 SWELLING
 DEFORMITIES
 LIMP
 STIFFNESS +loss of function
 Snapping
 Limb length discrepancy

HISTORY
CHIEF COMPLAINTS
DURATTION ONSET
PROGRESSION OF THE SYMPTOMS
PERTAINING TO VARIOUS AETIOLOGY
CONSTITUTIONAL SYMPTOMS
COMORBIDITIES
HABITS
TREATMENT TAKEN
OCCUPATION AND RECREATIONAL DEMANDS
EFFECT ON DAILY ACTIVITIES (ADL)

l Pain
 Duration –
 Onset –
 Progress –
 Is it constant or intermittent?
 localization
 Severity-
 Character
 Radiation-
 Aggravating and relieving factors-
 Diurnal variation-
 timing. NIGHT PAIN ( NOCTURNAL PAIN)- NIGHT CRY
 Associated symptoms

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
(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

SWELLING , STIFFNES
 Site
 Onset
 Duration
 Association with pain
 Progression over time
 PROGRESSION –
STATIONARY
INCREASING -
REGRESSING

LIMP
 Onset
 Duration
 Association with pain
 Progression
 Ambulatory status
 PROGRESSION OF LIMP (GRADES)
 LIMP WITHOUT AID
 LIMP WITH AID
 WHEEL CHAIR BOUND
 BED RIDDEN

l Deformity
How long the deformity is present?
How did it start?
How is it progressing?
Any associated symptoms?
Is there any history of trauma or infection?
l Limb length discrepancy
How long it is present?
Is it static or progressive?
Associated symptoms?
Any history of infection or trauma?

l History to assess function
 Walking ability
Normal or altered
Restricted or unrestricted
Aided or unaided
If aided; which aid is used
 Ability to squat
 Ability to sit cross legged
 Ability to drive car
 Ability to tie shoes

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

PERSONAL HISTORY
Occupation and work
tolerance
Diet
Smoking/alcohol
Sexual history
Menopausal history

FAMILY HISTORY
TBin close relative
Dysplasia
Metabolicstorage disorders
Inflammatory arthritis

SUMMARY OF HISTORY
ACUTE / CHRONIC
PROGRESSIVE / NON PROGRESSIVE /REGRESSIVE
MONOARTICULAR / POLYARTICULAR
POSSIBLE AETIOLOGY
(CONG./TRAUMATIC/INFECTIVE/INFLAMMATORY/NEO
PLASTIC/DEGENERATIVE/ METABOLIC ETC)
PATIENT’S DEMAND / EXPECTATION

Pattern of Examination
l Inspection.
l Palpation.
l Movements.
l Measurements.
l Special tests.

Basic Principles
( Prerequisites of Examination )
l Patient must be suitably undressed.
l Hard bed.
X

GENERAL EXAMINATION
Head to foot examination
l Eyes- Blue sclera, iritis ,uveitis, squint, microphthalmos, cornea,
pigmentation of sclera.
l Pinna- Low set, blackish discoloration.
l Cheeks- Malar rash.
l Mouth – Normal dental hygiene, arch of palate.
l Hair Line- Normal or low
l Neck – Webbing , thyroid swelling.
l Nipples- Normal level or not.
l Shape of chest wall- Pectus carinatum/ excavatum.
l Abdomen- Protuberant , undescended testis , hernias.
l Nails- Pitting.
l Palms and soles- Hyperkeratosis.

GENERAL EXAMINATION
Head to foot examination
l Thickening of lower end radius, malleoli and costochondral junctions.
l Ligamentous laxity
 Apposition of thumb to flexor aspect of forearm
 Passive extension of fingers so that they lie parallel to the forearm.
 Hyperextension of elbow at least 10 degrees
 Hyperextension of knee at least 10 degrees
 Excessive passive dorsiflexion of ankle (45 degree) with eversion of foot.
l Neurocutaneous markers-
l General postures and altitude

Inspection
l with the patient
_ standing,
_ walking,
_ sitting and
_ lying down.
l Look from the front, sides and back.
l Look for any asymmetry when compared to the
normal side.

Inspection
l Standing position.
Inspection
Gait
Alignment
Limb Length Discrepancy
l Lying down position.
 Limb Length Discrepancy
ATTITUDE

l General Inspection
 Observe the patient first in the standing
position
 Stand with the patient facing you.
 Be prepared to support the patient, as they may
not be able to stand unaided.
 considering the patient as a whole. Consider if
the patient looks well, is breathless at rest, is
jaundiced or has generalized features of
psoriasis or rheumatoid arthritis.

Inspection.
l Look for general clues
 Any walking frame,
 special shoes or orthosis present?
 Does the patient use a stick and is it in the
correct hand?
 Ask the patient is they have a walking stick
 Talk to the patient; explain what you are going
to do Work around the hip 360° get used to
using a small space

l General Inspection
l Observe the patient from
 the front,
 the side and
 then back.

Look for the following.
 Attitude
 Deformity
 Bony contours
 Soft tissue contours
 Swelling
 Wasting
 Limb length discrepancy
 Skin over the joint

Hip inspection from the Front
l Does the patient stand straight and upright?
l Is stance comfortable?
l Is stance symmetrical?
l Are the shoulders level?
l Check the level of the ASIS .Is the pelvis symmetrical? If not
level…. why not? What is causing the pelvic obliquity
l • Is there a leg length discrepancy
l • Is there a fixed deformity Ask for blocks if the
pelvis is not level to access functional leg
length discrepancy.

Hip inspection from the Front
 Is there any deformity in the coronal plane e.g.
Abduction/adduction contracture of the hip
 Any thigh or calf wasting?
 Is the patient taking weight equally through
both legs?
 Look at the feet, is the foot taking weight in a
plantigrade fashion or is the ankle or foot
inverted, everted or in equines.
 Inspect the skin for scars, sinus, evidence of
circulatory disturbance etc. “Can you push
your knee back fully straighten your leg”

Anteriorly from proximal to distal
 Level of ASIS
 Normal hollowing of iliac fossa
 Inguinal orifices
 Widened perineum
 Femoral artery pulsations
 Abnormal fullness in the Scarpa’s triangle
 Contour and level of the greater
trochanter
 Contour and bulk of the thigh muscles
looking for abnormal contour and wasting
 Scars, discolorations, swellings and
sinuses

LOOK
FROM
THE
FRONT
FOR
PELVIC OBLIQUITY
Concealed FIXED / NONFIXED
ASIS
depressed-
Fixed ABD
def
ASIS
elevated-
Fixed ADD
def
Bahaa Ali Kornah_Al.Azhar Un. Cairo . EGYPT

Hip inspection from the Side
 increased lumbar lordosis or is the
patient standing with a stoop?
 Is there a flexion contracture of the hip or
knee? (Deformity in the axial plane)
 Are there any scars from previous surgery
or disease?
 Is there bruising? a sinus or dressings
present?

from the Side=Laterally:
 Exaggerated lumbar lordosis
 Position and bulk of the trochanter-
Excessive lateral prominence is seen in
subluxation/dislocation.
 Reduced prominence seen with protrusio
acetabuli.
 Scars sinuses or any abnormal
prominences

Hip inspection from the Side
 ask the patient “Can you point to where the
pain is?
 points to the groin it is probably arising
from the hip joint,
 points to their back or buttock it suggests
possible referred pain from the spine to the
hip
 a C sign with their hand over the painful hip
which is a very specific sign for hip disease

Hip inspection from the Back
 Does the patient have a straight or
scoliotic lumbar spine, and if so, is it
compensated or not.
 Check for any gluteal muscle
(buttock) wasting Look at the
popliteal creases,
 You are assessing forward flexion
checking the spine for symmetrical
movement, normal rhyme

from the Back=Posteriorly:
 Scoliosis
 Level of PSIS and iliac crests
 Symmetry of the gluteal folds
 Wasting of gluteal muscles
 Scars, sinus or abnormal
masses

Inspection
In standing position
l Patient able to stand – Yes / No.
l If yes, patient able to walk – Yes / No.
l If yes, check Gait.
l Gait :
_ Trendelenburg.
_ Antalgic
_ Waddling
_ Short legged
_ High stepping
l Patient able to squat or not.

Inspection
l Spine.
l Wasting e.g. Disuse atrophy, neurological
deficit.
l Swelling e.g. Cold abscess, dislocation,
lipoma.
_ Scarpa's triangle.
_ Greater trochanter.
_ Gluteal region
l Scars / Sinus
l Level of natal fold e.g. CDH.

Inspection
l Observe gait
l Check hip and pelvis area for skin abrasions,
abnormal swelling, etc.
l Check if the anterior superior iliac spines are
in the same horizontal plane or tilted pelvis
l Observe the two discernible dimples to check
PSIS for pelvic obliquity

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
Limping is the most common
abnormality
Can be defined as any
abnormality of normal
rhythmic biphasic walking

GAI
T
LIMB
TRUN
K

Gait
l Abnormalities of gait
 Antalgic gait
 Trendelenburg gait
 Short leg gait
 Drop foot gait
 Gluteus maximus gait
l Circumduction gait step
l Stiff hip gait
l Quadriceps lurch
l Stiff knee gait
l Waddling or duct gait

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

Waddling gait
Body sways from side
to side on a wide base
seen in bil. DDH,
pregnancy

Trendelenberg gait
In double stance forces
distributed equally over two
hips
In single stance forces
increases 6 fold
Patient lurches on the
affected side and pelvis
drops on to sound side

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

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

Gluteus maximus gait-
In paralysis of gluteus
maximus
Pt lurches
backward during
stance phase

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

Toe in gait
Pt walks with both feet
turned inwards-
seen in femoral
anteversion

Toe out gait
Pt walks with both
feet turned outwards-
seen in femoral
retroversion

Inspection
l Trendelenburg test

l Trendelenburg Testing
l In 1895 Friedrich Trendelenburg described
observations on the gait of congenitally
dislocated hip patients. Later he went on to
describe the pelvic inclination on single leg
weight bearing, which became known as the
Trendelenburg test. This test has been
modified repeatedly since the original
description.

l Method 1 Stand in
front of the patient
and ask them to
hold their hands out
in front and place
their hands in your
hands for balance.
Ask the patient to
stand on their
normal leg fir

True positive (weakness of
abductors)
l • A Trendelenburg test is positive for two main
reasons either a
l Neuromuscular condition • or
l Mechanical conditions

l Neurological causes
l can be generalized or localized.
Generalized motor weakness
1. spinal cord lesions or myelomeningocele.
localized neurological
a) Gluteal muscle paralysis or weakness (superior gluteal
nerve injury)
b) superior gluteal nerve dysfunction secondary to previous
hip surgery.
c) Polio, neuromuscular conditions,

The mechanical group includes
1. conditions that affect the abductor
muscle lever arm,
2. • • Osteoarthritis
3. short neck in coxa vara, hip fractures
etc.
4. DDH Fulcrum failure
5. • Post THR exposure with failure of
adequate repair
6. • Trochanteric osteotomy Lever (pivot)
failure
7. • #NOF; #ITF,,

l False positives
_ Gluteal inhibition due to pain secondary to • OA • AVN
_ Hip pain makes proper assessment of these cases difficult If
pain is not considered a true positive It has been suggested
that a 10% rate of false positives occur
l False negative
_ • Arthrodesis or ankylosed hip Able to maintain abduction with
no abductor function
l False-positive and false-negative responses
_ may occur, but their interpretation can be clarified if the test is
properly performed
_ Invalid if • Poor balance • Lack of co-ordination • Unable to
understand instructions

Inspection
In lying down position
Sequential -
Top to bottom
or
Bottom to top.

Inspection
In Lying down position
• Attitude.
• Lumbar lordosis.
• ASIS.
• Greater trochanter
• Position
• Prominence

Wide Perineum Lateralized Contour

Inspection
l Scarpa's triangle
_ Fullness.
_ Scars / sinus.
l Skin
_ Colour, texture, prominent veins.
l Thigh
_ Wasting.
l Patella
_ Position

Inspection
l Calf
_ Wasting
l Malleoli
_ Level
_ Direction.
l Heel
_ Level
l SLR

l look for
l asymmetry,
l APPARENT DFORMITIES and
l rotational alignment of the legs
l Any obvious shortening position as
the affected leg
l Leg Shortening

Palpation
l Superficial palpation
_ Skin temp
_ Skin condition
_ Scars
_ Sinuses :
• Margins, Discharge, adherence to bone
_ tenderness,
_ bony thickening or
_ swelling,
_ soft tissue mass or defect.
_ Medial malleolus
• How to feel?
• Level & direction
_ Heel Level

N)
PALPATIO
N
ANTERI
OR
WARMT
H
JOINT
LINE
TENDERNE
SSSWELLI
NG
LATER
AL
TROCANT
ER
WARMTH
TROCHANTERIC
TENDERNESS
BI-TROCHANTERIC
RETRO-TROCH
TENDERNESS
POSITION
SURFACE
THICKNESS(GI
RTH)
CREPITUSPOSTERI
OR
HEAD OF
FEMUR
POST JOINT
TENDERNESS
MEDIA
L
SWELLIN
G
TENDERN
ESS
PELVIC
TENDERNE
SS

Palpation
Confirmation of inspection findings in same
sequence plus few additions :
Temperature, Tenderness & Telescope
l Lumbar lordosis
_ Thomas’s test for FFD.

Palpation
l ----Anterior Superior Iliac Spines (ASIS): check pelvic
obliquity
l ----Iliac crest ( gluteus and Sartorius muscles originate
just below it)
l ----Greater Trochanter (uneven in congenital hip
dislocation or poor-healed hip fx)
l ----PSIS (lie directly underneath the visible dimples just
above the buttocks, check for pelvic obliquity)
l ----Trochanteric Bursa (have pt. lie on the side with hip
flexion; If it is inflamed, the area feels boggy and tender to
palpation)

l Anteriorly:
l temperature
l Anterior joint line tenderness-
l Confirm level of ASIS.
l Feel the resistance over the Scarpa’s triangle.
l Femoral pulsations-
l (Vascular sign of Narath).

FEEL THE TENDERNESS
ANTERIOR JOINT
TENDERNESS
TROCHANTERIC
TENDERNESS
FEMORAL
MEDIAL JOINT
TENDERNESS
MID
INGUINAL
POINT
2 CM BELOW
AND
LATERAL
OEVR THE
TROCANTE
R
at
midinguinal
point
JUST
POSTERIOR TO
ADD. LONG.

RETRO-TROCHANTERIC
TENDERNESS
MILDLY INT-
ROTATE
POSTERIOR
TO
TROCANTER

Palpation
_ Thomas’s test for FFD.
_ Test with knee flexion deformity

Thomas’s test for FFD

CRITICISM OF THOMAS TEST
Painful hip
Obese or heavily built
individuals
B/L fixed flexion
deformity of the hip
In presence of ankylosed
knee.

Palpation
l ASIS level
_ How to feel ?
_ Level.
l Greater trochanter
_ Position, Province (Bitrochanteric test).
_ Tenderness – Antero posterior / Axial.

palpate
l Laterally:
_ Greater trochanter
_ Level in both supero-inferior as well as antero-posterior
directions.
_ Surface – Smooth or irregular or is it thickened.
_ Tenderness both local and on thrust
l Posteriorly:
_ Any mass- Globular bony mass that moves with the femur is suggestive of
dislocated femoral head in presence of an unstable hip.
_ Posterior joint line tenderness- Located at the junction of the lateral one
third and the medial two third of a line connecting the posterior superior
iliac spine (PSIS) and greater trochanter.

Movement
l Active
l Passive
l ROM depends on the age, gender and race.
Children and women have greater range of
movement. Elderly will have lesser range of
motion. Asian populations have greater range of
movement.

ACTIVE AND
PASSIVEPASSIV
E :
 RANGE
 ASSOCIATED PAIN
 MUSCLE SPASM
 CREPITUS
 INSTABILITY
MOVEMENTS

Movements at the Hip
l 1. Flexion / Extension
l 2. Adduction / Abduction
l 3. Lateral (external)Rotation / Medial (internal)
Rotation

l Normal ROM in Hip in adults
l Flexion 1200
l Extension 100
l Abduction 400
l Adduction 400
l Internal rotation in flexion 350
l Internal rotation in Extension 300
l External rotation in flexion 450
l External rotation in Extension 400
l Circumduction Incomplete

Movements
The important points to be noted
l 1. Is the range of movements normal?
using a goniometer.
2. If restricted; which movement is restricted?.
3. If restricted; what is the severity?
4. Is the movements painless, painful?
5. If painful; during which movement and during
which part of the arc of movement?
6. Is the limitation of movement due to mechanical
causes or due to pain and spasm?
7. Is the axis of movement normal?.
8. Was there any exaggeration of the normal
movements?

FLEXION

ABD + ADDUCTION

EXTENSION

Movements
Externalrotation
90 deg
flexion(45 deg)
full
extension(45deg)

Movements
Internal rotation
Internal rotation in 90 deg
flexion(45 deg)
Internal Rotation in
full extension(45 deg)

Hip Rotation
prone position

Hip Rotation sitting position

Hip Flexors
l Iliopsoas (prime hip flexor)
l Pectineus
l Sartorius
l Rectus femoris
l Pectineus
l Tensor fasciae latae
l Adductor brevis
l Adductor longus
l Adductor magnus (anterior head)
l Rectus femoris

Hip Extensors
l Gluteus maximus
l Biceps femoris (long
head)
l Semitendinosus
l Semimembranosus
l Adductor magnus (posterior head)

Hip Abductors
l Gluteus medius
l Gluteus minimus
l Sartorius

Hip Adductors
l Adductor brevis
l Adductor longus
l Adductor magnus
l Gracilis
l Pectineus

Internal Rotators of the Hip
l Gluteus medius
l Gluteus minimus
l assisted by the adductors
brevis and longus and the superior
portion of the adductor magnus
l

External Rotators of the Hip
 piriformis,
 superior and inferior
gemelli,
 obturator internus,
 obturator externus.
 quadratus femoris

Special tests
l Special tests are done as required depending on
the clinical diagnosis. They can be divided into the
following.
l 1. Tests to assess limb length discrepancy
2. Tests for stability
3. Tests for deformity assessment
4. Tests for impingement
5. Tests for muscle contracture
Tests to assess limb length
discrepancy

Leg Length Discrepancy (LLD)
l Leg Length Discrepancy (LLD)
l True LLD: measure from ASIS to the medial malleoli.

Leg length discrepancy
l Apparent LLD: (determine no TLLD first)with
pt. supine, measure from umbilicus to the
medial malleoli. Apparent discrepancy may be
caused by pelvic obliquities or flexion or
adduction deformity of the hip.

l True and Apparent Leg Length
l How to Examine Leg Shortening?
_ Block Method
_ Supine Position
l Where is the Shortening?
_ Is it femoral or tibial?
l Where in Femur?
_ Bryant’s triangle
_ Nelatons line
_ Chiene’s line or parallelogram

Measurements
Apparent : Lengthening / Shortening.
l Pre requisite
_ Limbs parallel
l Measured between midline
point –
1. Xiphisternum,
2. Manubrium sterni or
3. Umbilicus
&
medial malleoli

Measurements
Real :True Lengthening / Shortening
l Pre requisites
_ Squaring of pelvis.
• ASIS at same level.
_ Limbs in identical
position.
l Measurement from
ASIS to medial
malleolus.

MEASURE
APPARENTTRU
E

ADDUCTION  APPARENT
SHORTENING
ABDUCTION  APPARENT
Apparent shortening &
lengthening

Measurements
l Segmental measurements
l Find level of discrepancy
_ Leg,
_ Thigh or
_ Supra trochanteric.

 Galeazzi's test = Galeazzi's sign
 Allis test
 whether the shortening is in the femur or tibia Flex the hips to 45º
and the knees up to 90º. Place the malleoli together
 Normally both knees are at the same level
 knee projects farther forwards =femur is longer or more usually
the contra-lateral femur is shorter
 When one knee is higher than the other, either the tibia of that
side is longer or the contra-lateral tibia is shorter

FEMORAL SEGMENT
SHORTENING
Tibial shortening

Square the pelvis
ASIS MEDIAL JOINT LINE KNEE MEDIAL
MALLEOLUS

Measurements
(How to detect supratrochanteric shortening)
l Bryant's triangle.
l Nealon's line.

BRYANT’S TRIANGLE NELATON’S LINE

Measurements
(How to detect supra trochanteric shortening
l Shoemaker's line.
l Chiene’s parallelogram

MEASUREMENTS
Morris’ Bitrochanteric Test:
• it measures the distance
between the GT and pubic
symphysis on both sides
•Reduced in hip dislocations

KOTHARI’S LINE

MEASUREMENTS
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
sequala
True shortening

MEASUREMENT- Muscle bulk
Muscle wasting

Special tests
following.
Tests for deformity
assessment

DEFORMITIES
Abnormal fixed position of the joint
Deformities along sagittal plain
( flexion, extension)
Deformity along mediolateral plain
( coronal plain)
{ abduction, adduction deformity}
Rotational deformity
{ external, internal rotation deformity}

Deformities along sagittal plain
Flexion deformity
• exaggeration of lumbar lordosis
• +ve Thomas test

HIP EXAMINATION
THOMAS TEST Flexion deformity
NORMAL LIMB
DISEASED LIMB

Tests for deformity assessment
l Staheli prone extension test
l Patient position- Prone with hip
and knees dangling beyond the
end of the examination table
l Interpretation- The angle between
the thigh and the table is the fixed
flexion deformity.

Deformities along
coronal plain
Pelvic tilting
Abduction: lowering of the
ASIS of the diseased side
Adduction: elevation of
the ASIS of the diseased side
Lateral deviation of the spine ( scoliosis)
+

FIXED ABDUCTION
Pelvic tilting
Pelvis compensates
by
lowering of the ASIS of
the diseased side

FIXED ADDUCTION
Pelvic tilting
Adduction
Pelvis
compensates
by
elevation of the ASIS of
The diseased side

ASIS –DEPRESSED –
FIXED ABDUCTION
SQUARE THE PELVIS BY
FURTHER ABDUCTION
CORONAL
DEFORMITY
ASIS-ELEVATED - FIXED
ADDUCTION
SQUARE THE PELVIS BY
FURTHER ADDUCTION

FIXED ABDUCTION & ADDUCTION
DEFORMITY
Pelvic tilt indicated by ASIS at
different level

DEFORMITY
DN

DEFORMITY
N
D

FIXED ABDUCTION – ADDUCTION
DEFORMITY

Alternate method for
determing
Fixed abduction & adduction
deformity
Kothari’s method

DEFORMITIES
Abnormal fixed position of the joint
Rotational deformity
{ external, internal rotation deformity}

Fixed external & internal
rotation deformity
Always remains revealed
Determined by noting the
direction of anterior surface
of patella or the toes when
the foot is held at right angle
to the leg

Tests for deformity assessment
l Craig’s test
l Patient position – Prone
FOR ANTEVERSION
1.POSITIONED PRONE
2.KNEE FLEXED 900
3.ONE HAND OVER
TROCANTER
4.OTHER HAND IS
ROTATING THE LEG TILL
THE TROCANTER FELT
PROMINENT
5.ANGLE SUBTENDED
BETWEEN THE IMAGINARY
VERTICAL TO THE LONG
AXIS OF THE LEG

Special tests
following.
Tests for stability

Tests for stability
l Trendelenburg test
l Described by Freidreich Trendelenburg in 1894.
l Patient position – Standing.
l Don’t do if hip has fixed adduction or
abduction deformity.

Tests for stability
l Telescopy test
(Piston or
Dupuytren’s test)
l Patient position –
Supine

Palpation ( contd. )
l Telescopy

Neonatal Examination for CDH
Feel a clunk
not hear a click !
Special Tests – Ortolani test

Special Tests – Barlow test
Neonatal Examination for CDH
Feel a clunk
not hear a click !

Tests for stability
l Gouvain’s test
l Patient position- Supine or
lateral position
l Procedure- Hold the femur
with one hand, stabilize the
pelvis. Adduct and internally
rotate the hip. Look for
spasmodic contraction of
muscles
l Interpretation- Seen in
Tuberculous hip with fibrous
ankylosis

PELVIC STRESS TESTS
LATERAL PELVIC
COMPRESSION TEST
ANTERIOR PELVIC
COMPRESSION
TEST

PELVIC STRESS TESTS
PUBIC SYMPHYSIS STINCHFIELD
TEST STRESS TEST

FULCRUM TEST
It tests for the stress
fractures of the shaft
of femur
Bahaa Ali

Special tests
following.
Tests for impingement

Tests to assess impingement
l The FABER (Patrick's) Test
l FABERE (Flexion-Abduction-External
rotation-Extension) test
l Patient position – Supine
l Procedure- Put the affected limb on the
opposite limb in the Flexion-Abduction-
External rotation (FABER) position or Figure 4
position. Apply hand over the medial aspect of
knee and force the hip into full abduction and
extension.
• TEND TO STRESS THE IPSILATERAL S-I
JOINT
• PAIN IS POSTERIOR IN S-I ARTHRITIS
• PAIN IS ANTERIOR IN HIP ARTHRITIS

l Scour test
l Patient position- Supine
l Procedure- Done by moving the hip in an arc

l Stinchfield test (Resisted
SLR test)
l Procedure- Ask the patient to
actively flex the hip to 30 degrees
while keeping the knee in
extension and to hold the position.
Apply resistance just proximal to
the knee.
l Interpretation- Pain felt in the
groin is suggestive of intra
articular pathology.

l Posterior impingement test
(Hyperextension-
Abduction-External
rotation (HEABER test))
l Procedure- Passively place the affected
hip in the Hyperextension-Abduction-
External rotation (HEABER) position.
l Interpretation- If there is catching type of
pain then test is positive.

l FADDIR (Flexion-
Adduction-Internal rotation)
test or Anterior
impingement test
l Patient position – Supine
l Procedure- Put the affected limb in the Flexion-
Adduction-Internal rotation (FADDIR) position.
Apply hand over the anterolateral aspect of
knee and force the hip into full adduction and
internal rotation.
l Interpretation- If there is catching type of pain
then test is positive.

l McCarthy test
on the couch.
l Procedure- Flex both hips fully.
Extend the affected hip.
l Interpretation- If patient complains
of catching pain the test is positive.

Special tests
following.
Tests for muscle contracture

Tests to assess muscle contracture
l Piriformis test (FAIR
(Flexion-Adduction-
Internal Rotation test)
l Patient position –
Lateral position with the
affected side up.
l Procedure- Flex the hip to 600 and flex the
knee. Stabilize the pelvis with one hand.
Hold the leg with other hand. Move the hip
into adduction and internal rotation with
gentle force.
l Interpretation- If there is pain in the
buttocks or sciatica then test is positive.

l Obers test
l Patient position – Lateral
position with the affected
side up. Opposite hip
and knee flexed to 900.
l Procedure- Flex the hip and the knee to 900.
Stabilize the pelvis with one hand. Hold the leg with
other hand. Move the hip into full abduction and
external rotation. Extend the knee and hip and let
the limb drop down due to gravity.
l Interpretation- Normally the limb should drop down
and rest on the couch. If the limb is held high in
abduction, there is contracture of the iliotibial band.

l Ely’s test
l Procedure- Flex the knee
fully. Observe for flexion of
hip.
l Interpretation- If the hip
flexes, there is rectus femoris
contracture.

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
PHELPS’ TEST

Thomas Test
l To assess hip flexion contractures
l Perform the test with the pt. supine, flex one
hip fully reducing the lumbar spine lordosis,
stabilizing the spine and pelvis, extend the
opposite hip. A flexion contracture is present if
the hip cannot fully extend. The degree of
flexion contracture can be done by estimating
the angle between the table and pt.’s leg.

l Examination of Gait:
l Front : Look at trunk , pelvis and swinging of hand
(contralateral to the hand)
l Back : Look at shoulder and pelvis:
l Side : Excessive Lordosis, ankle plantar flexion
and knee flexion, hip and knee extension.

Remember
l Examination of the opposite hip, knee and
spine
l Examination of the sacroiliac joint
l Examination of the distal neurovascular deficit
l Per rectal examination

Examination
l Examination of hip is incomplete without
examination of spine & knee.

Key to Examination findings
ASIS at same level No adduction or
abduction deformity
Apparent
measurements =
Real measurements
ASIS raised Adduction
deformity
Apparent
shortening > Real
shortening
ASIS lower Abduction
deformity
Apparent
lengthening > Real
lengthening

Neurologic Exam
l Muscle testing: test muscle strength in
functional groups.
l Primary flexor: Iliopsoas (femoral N. L1,2,3)
l Primary extensors: Gluteus Maximus (inferior gluteus N. S1)
l Primary adductors: Adductor longus (obturator N. L2,3,4)
l Primary Abductor: Gluteus medius( superior gluteal N., L5)
l Sensation testing: for example, dermatomes (
T10-L3)

l DIAGNOSIS
l Anatomical : Synovitis/Arthritis/Coxa
vara/Unstable hip/ Ankylosis of hip
l Pathological :
Traumatic/Inflammatory/Neoplastic/Infective/
Degenerative

‫قرنة‬ ‫بهاء‬
Bahaa Kornah
bkornah@hotmail.com
l .

Hip examination

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