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Trendelenburg Test

 Trendelenburg Test


Trendelenburg Test is used to identify weakness of the hip abductor muscles. It also can be used to assess other mechanical, neurological or spinal disorders, such as the Congenital dislocation of the hip or hip subluxation.

The Trendelenburg sign indicates weakness of the gluteus medius muscle during unilateral weight-bearing.

This test was originally described by “Duchenne de Boulogne” in 1867 but was rediscovered by Friedrich Trendelenburg in 1895 for assessment of DDH.

See Also: Pelvic Anatomy

How do you do the Trendelenburg Test?

  • Stand behind patient. Observe the angle between pelvis (line joining iliac crests) and ground. Ask patient to stand on unaffected side first, lifting affected side foot and flexing hip between neutral and 30° and knee to clear foot off the ground (this is done to nullify the effect of rectus femoris). Note the position of pelvis. In some patients to maintain balance either a supporting stick can be used on the hand of weight-bearing hip or examiner can support both shoulders.
  • Then ask patient to raise the affected side of pelvis as high as possible. (One may provide support to the patient by holding arm of the weight-bearing side). Correct any tendency to lean over the weight bearing side by bringing shoulders at same level.
  • Repeat the same on affected side (the side to be tested). Interpretation: Normally (“negative test”) one is able to lift the other side (watch iliac crest) without losing balance for at least 30 sec and the lift is equal to the abduction possible at that hip. Gluteal folds have been long propagated as ‘standard’ reference for judging pelvic lift but a lot of limitations arise primarily due to muscle wasting so common in hip disorders. PSIS is a good reference if there is significant gluteal wasting or folds are asymmetrical, however it is too near to midline to judge pelvic lift and be taken as a primary reference.

Alternately one can less reliably stand in front of patient and support patient’s palm. Perform the test the same way but notice the pressure transmitted by patient’s palm when they attempt to balance. Increased pressure in opposite side in an attempt to gain support from you suggests positive test.

This position produces a strong contraction of the gluteus medius, which is powerfully assisted by the gluteus minimus and Tensor Fascia Latae muscles, in order to keep the pelvis horizontal. For example, when the body weight is supported by the left foot, the left hip abductors contract both isometrically and eccentrically to prevent the right side of the pelvis from being pulled downward by gravity.

Trendelenburg Test
Trendelenburg Test

What does a positive Trendelenburg test mean?

The Trendelenburg sign is positive if:

  1. Maximal elevation not achieved.
  2. Sustained elevation not achieved (for 30 sec): Delayed abnormal response.
  3. Iliac crest not elevated (pelvis parallel to ground).
  4. Pelvis drops down (opposite iliac crest).

Negative test: when the pelvis on the nonweight bearing side raises as high as possible and is capable of maintaining it for 30 seconds with the vertebra prominens centered over the hip and foot.

False-positive Trendelenburg test can occur with:

  1. fixed abduction contracture,
  2. painful abduction,
  3. in poor balance due to generalized weakness especially in elderly people.

false negative Trendelenburg test can be produced by:

  1. Use of suprapelvic muscles by patient,
  2. use of psoas and rectus femoris,
  3. wide lateral translocation of trunk to allow balance over the hip as a fulcrum.

Causes of a positive Trendelenburg test

Several dysfunctions can produce a positive Trendelenburg Test:

  1. Weakness of gluteus medius muscle.
  2. Hip instability and subluxation.
  3. Hip osteoarthritis.
  4. Initially post Total Hip Replacement.
  5. Superior Gluteal Nerve Palsy.
  6. Lower back pain.
  7. Legg-Calvé-Perthes Disease.
  8. Congenital hip dislocation.

A Trendelenburg gait can also be observed caused by abductor insufficiency and is characterized by:

  1. Pelvic drop in swing phase.
  2. Trunk side flexion towards the stance limb.
  3. Hip adduction during stance phase.
See Also: Gait Cycle

Trendelenburg Test Accuracy

A Systematic Review for diagnostic validity of the physical examination maneuvers for hip pathology on 40 patients with unilateral lateral hip pain, the Trendelenburg test demonstrated some evidence for use in a clinical setting in diagnosing gluteal tendon pathology:

  • Sensitivity= 23 %
  • Specificity= 94 %

Another study on 24 patients with lateral hip pain and tenderness over the greater trochanter, the Trendelenburg Test has a sensitivity of 73% and a specificity of 77%.

Notes

  • In the single leg stance, the pelvic and trochanteric musculature (gluteus medius and gluteus minimus) on the weight-bearing side contract and elevate the pelvis on the unsupported side, holding it nearly horizontal. This process allows uniform gait.
  • Where the gluteal muscles are compromised (weakened as a result of a hip dislocation, due to paralysis, or following multiple hip operations) with functional deficits, they are no longer able to support the pelvis on the weight-bearing side. The pelvis then drops down on the normal, non–weight-bearing side (positive Trendelenburg sign).
  • If the Trendelenburg test is present bilaterally it produces typical waddling gait (duck walking).
  • The drop in the pelvis toward the unaffected side also shifts the body’s center of gravity in that direction. Patients usually compensate by shifting the body toward the weight-bearing leg.
  • It it possible to mask trendelenburg’s sign or resulting gait by carrying a weight of 6-7 Kg on the affected side while walking, the lurch can be largely obliterated. This is due to shift of center of gravity towards the affected side and hence masking the weakness.

Prerequisites for doing the Trendelenburg test

There are a lot of limitations that itself are frequently seen in hip pathologies, so it is not a very good test:

  1. It should not be a very painful hip (spuriously positive).
  2. There should be no abduction or adduction deformity in any hip.
  3. Quadratus lumborum must be normal (affected in polio): this effects a normal Trendelenburg test.
  4. In obese and patients with medial shift of lower limb mechanical axis the test may be pseudo-positive.
  5. Sacroilitis may produce a positive test.

Grading of the Trendelenburg sign:

NegativePatient can lift the pelvis on the non–weight-bearing side
Weakly positivePatient can maintain the position of the pelvis on the non–weight bearing side but not lift it
PositivePelvis on the non–weight-bearing side drops visibly
Grading of the Trendelenburg sign (from Hoppenfeld 1982)

Related Anatomy

Hip abductors consists of 3 muscle: Gluteus medius, Gluteus minimus and Tensor fasciae latae (tensor fasciae femoris).

MuscleOriginInsertionInnervation
Gluteus mediusIlium between posterior and anterior gluteal linesGreater trochanterSuperior gluteal
Gluteus minimusIlium between anterior and inferior gluteal linesAnterior border of greater trochanterSuperior gluteal
Tensor fasciae latae (tensor fasciae femoris)Anterior iliac crestIliotibial bandSuperior gluteal
Hip abductors
Hip abductors

Common Questions:

What does the Trendelenburg sign test for?

Trendelenburg Test is used mainly to identify weakness of the hip abductor muscles.

How do you test for Trendelenburg gait?

The examiner stands behind the patient and observes the angle made between the line joining the iliac crests (pelvis) and the ground. The patient raises the foot on the opposite side being tested with the hip kept between neutral and a flexion of 30°. The position of the pelvis is noted.

What are the common causes of positive Trendelenburg test?

1. Weakness of gluteus medius muscle.
2. Hip instability and subluxation.
3. Hip osteoarthritis.
4. Initially post Total Hip Replacement.
5. Superior Gluteal Nerve Palsy.
6. Lower back pain.
7. Legg-Calvé-Perthes Disease.
8. Congenital hip dislocation.

Is Trendelenburg test reliable?

A systematic review found poor-to-good sensitivity and good-to-excellent specificity in adult populations with gluteal tendinopathy and gluteus medius strains.

Reference

  1. Youdas JW, Madson TJ, Hollman JH (2010) Usefulness of the Trendelenburg test for identification of patients with hip joint osteoarthritis. Physiother Theory Pract 26: 184-194. PMID: 20331375.
  2. Pasic, Nick; Bryant, Dianne; Naudie, Douglas; and Willits, Kevin, “Diagnostic Validity of the Physical Examination Maneuvers for Hip Pathology: A Systematic Review” (2014). Kinesiology Publications. 12.
  3. Woodley SJ, Nicholson HD, Livingstone V, et al. Lateral hip pain: findings from magnetic resonance imaging and clinical examination. J Orthop Sports Phys Ther. 2008;38:313-328.
  4. Bird PA, Oakley SP, Shnier R, Kirkham BW. Prospective evaluation of magnetic resonance imaging and physical examination findings in patients with greater trochanteric pain syndrome. Arthritis Rheum. 2001;44:2138-2145.
  5. Pasic N, Bryant D, Naudie D, Willits K. Diagnostic validity of the physical examination maneuvers for hip pathology: a systematic review. Orthopedic Muscul Syst. 2014;3:157.
  6. Clinical Tests for the Musculoskeletal System, Third Edition book.
  7. Mark Dutton, Pt . Dutton’s Orthopaedic Examination, Evaluation, And Intervention, 3rd Edition Book.
  8. Campbel’s Operative Orthopaedics 13th Edition Book.

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