Hip Physical Exam

Hip Physical Exam consists firstly of history taking, then joint inspection, palpation, movements and special tests performing. Hip physical exam should also include assessment of the knee, lumbar spine and pelvis

History Taking

Hip conditions can present with a range of symptoms: stiffness, limping, instability, clicking, snapping, clunking, recurrent falls and pain. The cardinal symptom is often pain, and an accurate history of the timing, onset and exact nature can be a useful tool to aid diagnosis. The location of pain may be vague and non-specific, and patients can present with groin, outer thigh and pain referred to the back, buttock or knee.

The timing of pain may also be relevant: early-morning pain that improves with activity throughout the day is suggestive of an inflammatory process, whereas pain which worsens with activity is suggestive of OA. Night pain which occurs in certain positions may be due to bursitis or tendinopathy. Constant night pain must raise the suspicion of joint pathology, including OA, infection or malignancy. Enquire about associated systemic symptoms of weight loss, fever and night sweats.

The nature of the pain can also give clues to the diagnosis; if the pain is sharp and acute with associated symptoms of ‘locking’ or giving way, consider labral pathology. Pain associated with specific movements can be related to a single musculotendinous unit, tendinitis or bursitis.

If the patient complains of stiffness, ask them what it most restricts them doing, and any exacerbating or relieving factors. The pattern of capsular restriction in the hip joint is internal rotation > flexion > abduction = extension > other movements. Exclude other anatomical sites as a source of ‘hip’ pain. In the lumbar spine, consider lumbar disc prolapse, OA, ankylosing spondylitis and malignancy. Enquire about peripheral neurological symptoms and consider peripheral nerve entrapment syndromes. Inguinal herniae, previous surgery in the inguinal region, psoas pathology, abdominal wall or intra-abdominal pathology can all present with hip pain and you should enquire about genitourinary or abdominal symptoms.

It is important to ask the patient about relevant past medical history: primary or secondary spine, hip, knee or ankle OA or any previous hip surgery. Ask if they had any hip problems or surgery in childhood, specifically developmental dysplasia of the hip (DDH), Perthes’ disease, transient synovitis, slipped capital femoral epiphysis (SCFE) and hip dysplasia. Past history of rheumatoid arthritis, Reiter’s syndrome, tuberculosis, or any other cause of septic arthritis in the hip joint is also relevant.

There are several validated scoring systems that assess different functional parameters, including pain, gait, activities of daily living, and some incorporate radiological findings. The modified Harris score is measured by an examiner and scored out of 100. Other widely used scores include the Oxford hip score, which is a questionnaire completed by the patient, and the WOMAC Osteoarthritis Index, which is not specific for the hip.

Hip Physical Exam

As we said, hip physical exam should include the following rule: Look (Inspection), Feel (Palpation) and Move (Movements) in addition to hip special tests.

Hip Joint Inspection

Begin with the patient standing, exposed to their underwear from the waist down. Inspect the hips for any obvious deformity or asymmetry, muscle wasting (particularly gluteal and quadriceps), skin changes, sinuses, previous surgical scars, bony prominences and leg length. Expose the spine and look for scoliosis, excessive lumbar lordosis, other deformity or scars from previous surgery.

Gait

Ask the patient to walk several paces away and then back towards you while watching the gait and posture. In particular, look for a Trendelenburg, antalgic or extensor lurch gait.

See Also: Gait Cycle

Trendelenburg test

This identifies abductor weakness, which can be due to pain, atrophy, polio or a mechanical disadvantage due to longstanding DDH or coxa vara.

See Also: Trendelenburg Test

Leg length

Apparent leg length shortening can be due to a fixed adduction deformity. Shortening can be ‘true’, where there is shortening of the femur or tibia, or apparent.

See Also: Leg Length Measurement

Hip Palpation

The hip is the deepest joint in the body and cannot be palpated directly; however, there are several important bony and tendinous landmarks that can be palpated around the hip joint. The ASIS is an important structure; it is used to determine alignment of the pelvis and marks the origin of sartorius and the tensor fascia latae.

The pubic tubercle is palpable lateral to the pubic symphysis at the medial end of the inguinal ligament. The origins of rectus abdominus and adductor longus tendons lie distally, and in the normal hip the pubic tubercle lies at the same level as the greater trochanter. This is more easily palpable along the posterior border, where there is less muscle coverage, and provides attachments for the abductors (gluteus medius, gluteus minimus) and short external rotators of the hip.

From behind, the posterior superior iliac spine can be palpated in the area of the sacral dimples, in addition to the ischial tuberosity, which provides attachments for the hamstrings and adductor magnus. The origin of adductor longus can be palpated distal to the pubic tubercle with the patient supine, knee flexed and hip abducted, which can be tender following an acute adductor strain and contracted in longstanding OA.

The insertion of iliopsoas can be palpated at the lesser trochanter with the patient supine while externally rotating the hip in neutral.

Hip Movements

Movements of the hip can be active, passive or resisted.

Active movements of the hip can give an indication of the range of movement and integrity of musculotendinous structures.

Passive movements are performed by the examiner to elucidate the maximal range of each movement, and the end-feel can be assessed: hard (bone), capsular, ligamentous or soft (soft-tissue approximation), elastic (e.g. hip flexion with knee in extension) or have an abrupt end due to protective muscle spasm.

Resisted movements test the integrity and power of individual or groups of musculotendinous units. This examination can elicit pain and weakness, which can be present alone or in combination. Weakness can be due to muscle/tendon rupture, tendinopathy, atrophy or pain. Muscle atrophy can be due to a central or peripheral neurological condition or result from disuse (e.g. as a result of hip pain from OA).

Hip Ragne of motion include the following values:

• Flexion (maximum 100–140°)
• Extension (maximum 10–30°)
• Abduction (maximum 30–60°)
• Adduction (maximum 20–45°)
• Internal rotation (IR) in 90° flexion (maximum 20–45°) in extension (maximum 20–35°)
• External rotation (ER) in 90° flexion (maximum 40–60°) in extension (maximum 40–50°).

Hip Examination Special Tests

The hip special tests that can be done in hip physical exam may include but limited to the following:

1. Thomas test
2. Duncan Ely’s test
3. Ober test
4. FABER Test (Patrick test)
5. FADDIR Test
6. Craig’s Test (Femoral Anteversion)
7. Stinchfield Test
8. Hip Quadrant Test
9. Ober Test
10. Noble Test
11. Leg Length Measurement
12. Hip Impingement Tests
13. Telescopy Test
14. Trendelenburg Test
15. Prone Hip Extension Test
16. Kraus Weber Tests
17. Bryant Triangle
18. Ortolani Test
19. Barlow Test
20. Step Down Test
21. Piriformis Syndrome Test
22. Patellar Tap Test
23. Log Roll Test

References & More

1. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.
2. Wichman D, Rasio JP, Looney A, Nho SJ. Physical Examination of the Hip. Sports Health. 2021 Mar;13(2):149-153. doi: 10.1177/1941738120953418. Epub 2020 Nov 20. PMID: 33217250; PMCID: PMC8167346.
3. Martin HD, Palmer IJ. History and physical examination of the hip: the basics. Curr Rev Musculoskelet Med. 2013 Sep;6(3):219-25. doi: 10.1007/s12178-013-9175-x. PMID: 23832778; PMCID: PMC4094013.
4. Byrd JW. Evaluation of the hip: history and physical examination. N Am J Sports Phys Ther. 2007 Nov;2(4):231-40. PMID: 21509142; PMCID: PMC2953301.