Hip examination

In medicine, physiotherapy, and chiropractic, the hip examination, or hip exam, is undertaken when a patient has a complaint of hip pain and/or signs and/or symptoms suggestive of hip joint pathology. It is a physical examination maneuver.

The hip examination, like all examinations of the joints, is typically divided into the following sections:

The middle three steps are often remembered with the saying look, feel, move.

Position/lighting/draping

Position - for most of the exam the patient should be supine and the bed or examination table should be flat. The patient's hands should remain at their sides with the head resting on a pillow. The knees and hips should be in the anatomical position (knee extended, hip neither flexed nor extended).

Lighting - adjusted so that it is ideal.

Draping - both of the patient's hips should be exposed so that the quadriceps muscles and greater trochanter can be assessed.

Inspection

Inspection done while the patient is standing

Look

Front and back of pelvis/hips and legs and comment on

  1. Ischaemic or trophic changes·
  2. Level of ASIS (anterior superior iliac spine)
  3. Swelling (soft tissue, bony swellings)
  4. Scars (old injuries, previous surgery)
  5. Sinuses (infection, neuropathic ulcers)
  6. Wasting (old polio, Carcot-Marie-Tooth) or hypertrophy (e.g. calf pseudo-hypertrophyin muscular dystrophy)
  7. Deformity (leg length discrepancy, pes cavus, scoliosis, lordosis, khyphosis)

Feel

  1. Any swellings·Anteriorly in scarpas triangle, Trochanteric region or gluteal region
  2. Pelvic tilt by palpating level of ASIS (anterior superior illiac spine)

Move·

Gait: Observe

  1. Smooth and progression of phases of gait cycle
  2. Comment on stance, toe-off, swing heel strike, stride and step length
  3. Sufficient flexion/extension at hip/knee ankle and foot:
  4. Any fixed contractures?
  5. Arm-swing and balance on turning around·

Abnormal Gait Patterns

  1. Trendelenburg (pelvic sway/tilt, aka waddling gait if bilateral)
  2. Broad-based (ataxia)
  3. High-stepping (loss of proprioception/drop foot)
  4. Antalgic (mention “with reduced stance phase on left/right side”)
  5. In-toeing (persistent femoral anteversion)

Inspection done while supine

The hip should be examined for:

Measures

In hip fractures the affected leg is often shortened and externally rotated.

Palpation

The hip joint lies deep inside the body and cannot normally be directly palpated.

To assess for pelvic fracture one should palpate the:

Movement

Normal range of motion

Special maneuvers

  1. Make sure pelvis is horizontal by palpating ASIS.
  2. Ask patient to stand on one leg and then on the other.
  3. Assess any pelvic tilt by keeping an index finger on each ASIS.
  4. Normal (Trendelenburg negative): In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing or even rise a little, because of powerful contraction of hip abductors on the stance leg.
  5. Abnormal (Trendelenburg positive): In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient isstanding on. This is because of (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal.
  6. Assisted Trendlenburg test If balance is a problem, face the patient and ask them to place their hands on yours to support him/her as he/she does alternate one-legged stance. Increased asymmetrical pressure on one hand indicates a positive Trendelenburg test, on the side of the abnormal hip
  7. A ‘delayed’ Trendelenburg has also been described, where the pelvic tilt appears after a minute or so: this indicates abnormal fatiguability of the hip abductors.

Romberg’s test This assesses proprioception/balance (dorsal columns of spinal cord/spino-cerebellarpathways).

  1. Ask the patient to stand with heels together and hands by the side. Ask the patient to close his/her eyes and observe for swaying for about 10seconds.
  2. Most people sway a bit but then quickly decrease the amplitude of swaying. If however, the swaying is not corrected, or the patient opens the eyes or takes a step to regain balance, Romberg’s test is positive.
  3. When doing this test, stand facing the patient with your arms outstretched and hands are at the level of the patient’s shoulders to catch or stabilise him/her in case of a positive Romberg’s test.

Kaltenborn test or Hip Lag Sign for hip abductor function. To perform the Kaltenborn test, the patient has to lie in a lateral, neutral position with the affected leg being on top. The examiner then positions one arm under this leg to have good hold and control over the relaxed extremity, whereas the other hand stabilizes the pelvis. The next step is to passively extend to 10° in the hip, abduct to 20° and rotate internally as far as possible, while the knee remains in a flexed position of 45°. After the patient is asked to hold the leg actively in this position, the examiner releases the leg. The Hip Lag Sign is considered positive if the patient is not able to keep the leg in the aforementioned abducted, internally rotated position and the foot drops more than 10 cm. To ensure an accurate result, the test should be repeated three times.[2]

Other tests

A knee examination should be undertaken in the ipsilateral knee to rule-out knee pathology.

See also

References

  1. 1 2 3 4 Prentice, William. Principles of Athletic Training. New York: Mc Graw Hill. 2011. print.
  2. ↑ Kaltenborn et al. 2014:(http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0091560

External links

 
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