Clinical Examination of the Hip

A systematic examination of the hip is essential for diagnosing musculoskeletal conditions involving the hip joint, surrounding soft tissues, and referred pain from the lumbar spine. A structured approach typically follows the standard orthopedic sequence: Look, Feel, Move, and Special Tests.

1. Observation (Look)

The examination begins the moment the patient enters the room. Observe the patients gait for antalgic patterns, pelvic tilt, or Trendelenburg signs. When the patient is standing, assess the following:

• Spine: Check for scoliosis or pelvic tilt.
• Pelvis: Assess for symmetry of the iliac crests.
• Soft Tissues: Look for muscle wasting (quadriceps or gluteals) or surgical scars.

2. Palpation (Feel)

Palpation is used to identify areas of tenderness, heat, or bony deformity. The patient should be supine for this portion of the exam:

• Greater Trochanter: Palpate for tenderness, which may indicate trochanteric bursitis.
• Inguinal Region: Palpate the inguinal ligament area. Tenderness here is often indicative of intra-articular hip pathology.
• Symphysis Pubis: Check for tenderness if pubic pathologies are suspected.

3. Range of Motion (Move)

Hip joint motion should be assessed both actively and passively. Always compare the affected side to the unaffected side.

• Flexion: With the knee flexed, bring the hip toward the chest. Normal range is 0120 degrees.
• Internal and External Rotation: These are the most sensitive movements for early hip joint disease. Perform these with the hip and knee flexed to 90 degrees. Normal range is roughly 045 degrees for each.
• Abduction and Adduction: Move the limb away from and toward the midline.
• Extension: Perform this with the patient in the prone position or by dangling the leg off the edge of the examination table (Thomas Test position).

4. Special Tests

Special tests are designed to provoke symptoms or isolate specific structures:

• Thomas Test: Used to detect fixed flexion deformities of the hip. The patient lies supine; the unaffected hip is fully flexed to flatten the lumbar spine. If the affected thigh rises off the table, the test is positive for a hip flexion contracture.
• Trendelenburg Test: Assesses the strength of the gluteus medius muscle. The patient stands on one leg. If the pelvis drops on the side of the lifted leg, it indicates weakness or paralysis of the gluteus medius on the stance leg.
• FABER Test (Patricks Test): The hip is Flexed, Abducted, and Externally Rotated (placing the ankle on the opposite knee). Pain in the hip or sacroiliac joint suggests pathology in those areas.
• FADIR Test: The hip is Flexed, Adducted, and Internally Rotated. This test is highly sensitive for femoroacetabular impingement (FAI) and labral tears.

5. Neurovascular Assessment

Although the primary focus is the hip, a brief neurovascular exam is necessary to rule out distal deficits. Check distal pulses (dorsalis pedis) and perform a quick neurological screen of the lower extremities, including dermatomes and myotomes, to ensure that symptoms are not originating from a lumbar radiculopathy.

Conclusion

The examination of the hip is a diagnostic process that relies heavily on the clinical history provided by the patient. By combining careful observation, systematic range of motion testing, and provocative special maneuvers, clinicians can effectively differentiate between intra-articular hip conditions, bursitis, and referred pain from the spine.